Healthcare Provider Details

I. General information

NPI: 1124248018
Provider Name (Legal Business Name): NORTH SHORE ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 ROUTE 25A SUITE 101
SMITHTOWN NY
11787-1431
US

IV. Provider business mailing address

48 ROUTE 25A SUITE 101
SMITHTOWN NY
11787-1431
US

V. Phone/Fax

Practice location:
  • Phone: 631-862-3540
  • Fax: 631-862-3604
Mailing address:
  • Phone: 631-862-3540
  • Fax: 631-862-3604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KERRI WOERNER
Title or Position: ADMINISTRATOR
Credential:
Phone: 631-862-3413