Healthcare Provider Details

I. General information

NPI: 1922603562
Provider Name (Legal Business Name): NETHERLANDS ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LEGION DR
LAS VEGAS NM
87701-4804
US

IV. Provider business mailing address

PO BOX 69342
BALTIMORE MD
21264-9342
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-3500
  • Fax:
Mailing address:
  • Phone: 833-352-0096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ALEX GORECKI
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 850-497-6702