Basic Information
| Provider Information | |||||||||
| NPI: | 1356891717 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEASTERN ANESTHESIA INSTITUTE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1373 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | CLIFTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070134200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013421205 | ||||||||
| FaxNumber: | 2013421259 | ||||||||
| Practice Location | |||||||||
| Address1: | 1373 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | CLIFTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070134200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013421205 | ||||||||
| FaxNumber: | 2013421259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2016 | ||||||||
| LastUpdateDate: | 10/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | PRVULOVIC | ||||||||
| AuthorizedOfficialFirstName: | TOMISLAV | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2013421205 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA06129800 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.