Provider Demographics
NPI:1356891717
Name:NORTHEASTERN ANESTHESIA INSTITUTE LLC
Entity type:Organization
Organization Name:NORTHEASTERN ANESTHESIA INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TOMISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:PRVULOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-342-1205
Mailing Address - Street 1:1373 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-4200
Mailing Address - Country:US
Mailing Address - Phone:201-342-1205
Mailing Address - Fax:201-342-1259
Practice Address - Street 1:1373 BROAD ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-4200
Practice Address - Country:US
Practice Address - Phone:201-342-1205
Practice Address - Fax:201-342-1259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06129800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty