Healthcare Provider Details

I. General information

NPI: 1669757654
Provider Name (Legal Business Name): SOVEREIGN ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2011
Last Update Date: 10/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 COURT ST
BROOKLYN NY
11231-4353
US

IV. Provider business mailing address

330 WYTHE AVE APT 5J
BROOKLYN NY
11249-4152
US

V. Phone/Fax

Practice location:
  • Phone: 718-422-5023
  • Fax:
Mailing address:
  • Phone: 917-692-7660
  • 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: CHARLES STARKE
Title or Position: OWNER
Credential: MD
Phone: 908-653-9399