Provider Demographics
NPI:1770530156
Name:RIVER EAST ANESTHESIA PRACTICE, PC
Entity type:Organization
Organization Name:RIVER EAST ANESTHESIA PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTH REP
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-423-4075
Mailing Address - Street 1:744 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1909
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:
Practice Address - Street 1:1879 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-2709
Practice Address - Country:US
Practice Address - Phone:212-423-4075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWE5631Medicare PIN