Basic Information
| Provider Information | |||||||||
| NPI: | 1972501740 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLTON ANESTHESIA GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE. 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087643566 | ||||||||
| FaxNumber: | 5087988012 | ||||||||
| Practice Location | |||||||||
| Address1: | 363 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027203703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086793131 | ||||||||
| FaxNumber: | 5086797146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PENHALLURICK | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5082793131 | ||||||||
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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 | 367500000X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 9704949 | 05 | MA | MEDICAID |