Basic Information
| Provider Information | |||||||||
| NPI: | 1891780078 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST ANESTHESIA ASSOC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE. 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5087988012 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 DORCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | DORCHESTER CENTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021245615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175062027 | ||||||||
| FaxNumber: | 6174743811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 04/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | TREMLBAY | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6175062028 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 9711341 | 05 | MA | MEDICAID |