Healthcare Provider Details

I. General information

NPI: 1104744523
Provider Name (Legal Business Name): FREE STATE ANESTHESIA SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10231 OLD OCEAN CITY BLVD STE 205
BERLIN MD
21811-3568
US

IV. Provider business mailing address

450 MAMARONECK AVE STE 201
HARRISON NY
10528-2436
US

V. Phone/Fax

Practice location:
  • Phone: 914-491-9495
  • Fax:
Mailing address:
  • Phone: 914-491-9495
  • Fax: 914-365-6326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARC E KOCH
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 914-491-9495