Provider Demographics
NPI:1669615894
Name:PROVIDENCE WA ANESTHESIA SERVICES, P.C.
Entity type:Organization
Organization Name:PROVIDENCE WA ANESTHESIA SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:E
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-400-3996
Mailing Address - Street 1:450 MAMARONECK AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-2436
Mailing Address - Country:US
Mailing Address - Phone:914-637-2075
Mailing Address - Fax:914-819-0061
Practice Address - Street 1:1321 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1665
Practice Address - Country:US
Practice Address - Phone:425-261-2000
Practice Address - Fax:800-886-1042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-17
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7146251Medicaid
WAG8880630Medicare PIN