Basic Information
| Provider Information | |||||||||
| NPI: | 1649457334 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARK ANESTHESIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 541 OTIS BOWEN DR | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463214158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199345300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 151 DUNDEE AVE | ||||||||
| Address2: | |||||||||
| City: | EAST DUNDEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601181648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475519601 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2008 | ||||||||
| LastUpdateDate: | 01/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEVI | ||||||||
| AuthorizedOfficialFirstName: | BAROUKH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2199345300 | ||||||||
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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 | 208VP0014X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01633948 | 01 | IL | IL BCBS | OTHER |