Basic Information
| Provider Information | |||||||||
| NPI: | 1548443153 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MANASSAS SURGERY CENTER ANESTHESIA SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 COMMERCE DR | ||||||||
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| City: | NEW ROCHELLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 108015214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146373510 | ||||||||
| FaxNumber: | 9148190061 | ||||||||
| Practice Location | |||||||||
| Address1: | 8409 DORSEY CIR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MANASSAS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201108305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035800181 | ||||||||
| FaxNumber: | 7038978763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2007 | ||||||||
| LastUpdateDate: | 08/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | KOCH | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 9146373511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1548443153 | 05 | VA | MEDICAID |