Provider Demographics
NPI: | 1952450090 |
---|---|
Name: | MAINLINE ANESTHESIA, PLLC |
Entity Type: | Organization |
Organization Name: | MAINLINE ANESTHESIA, PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MARTIN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | AZNAVOORIAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 917-734-2288 |
Mailing Address - Street 1: | PO BOX 270 |
Mailing Address - Street 2: | |
Mailing Address - City: | MASSAPEQUA PARK |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 11762-0270 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 631-264-2035 |
Mailing Address - Fax: | 631-264-1418 |
Practice Address - Street 1: | 1 E 68TH ST |
Practice Address - Street 2: | |
Practice Address - City: | NEW YORK |
Practice Address - State: | NY |
Practice Address - Zip Code: | 10021-4903 |
Practice Address - Country: | US |
Practice Address - Phone: | 212-570-6945 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-01-09 |
Last Update Date: | 2007-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | WFW951 | Medicare PIN |