Basic Information
| Provider Information | |||||||||
| NPI: | 1669615894 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE WA ANESTHESIA SERVICES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 MAMARONECK AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105282436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146372075 | ||||||||
| FaxNumber: | 9148190061 | ||||||||
| Practice Location | |||||||||
| Address1: | 1321 COLBY AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252612000 | ||||||||
| FaxNumber: | 8008861042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2009 | ||||||||
| LastUpdateDate: | 04/03/2019 | ||||||||
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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 | 7146251 | 05 | WA | MEDICAID |