Basic Information
| Provider Information | |||||||||
| NPI: | 1689668733 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOHAWK ANESTHESIA ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2005 | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130574505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154490513 | ||||||||
| FaxNumber: | 3154452936 | ||||||||
| Practice Location | |||||||||
| Address1: | 2210 TROY RD | ||||||||
| Address2: | |||||||||
| City: | NISKAYUNA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123094725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183469566 | ||||||||
| FaxNumber: | 5183469565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHUDA | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5183469566 | ||||||||
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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 | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 02409570 | 05 | NY | MEDICAID |