Basic Information
Provider Information | |||||||||
NPI: | 1316051196 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DELAWARE ANESTHESIA ASSOCIATION LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1780 COUNTY HIGHWAY 41 | ||||||||
Address2: |   | ||||||||
City: | ROXBURY | ||||||||
State: | NY | ||||||||
PostalCode: | 124741408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5736865550 | ||||||||
FaxNumber: | 5736862139 | ||||||||
Practice Location | |||||||||
Address1: | 42084 STATE HIGHWAY 28 | ||||||||
Address2: |   | ||||||||
City: | MARGARETVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 124552820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5736865550 | ||||||||
FaxNumber: | 5736862139 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARRACLOUGH | ||||||||
AuthorizedOfficialFirstName: | VICTOR | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5736865550 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CRNA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X |   | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | NY132615 | 01 | NY | WELLCARE NY GROUP | OTHER |