=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023497203
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW YORK ANESTHESIOLOGY MEDICAL SPECIALTIES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2015
-----------------------------------------------------
Last Update Date | 05/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5417 WEST GENESEE STREET SUITE 1
-----------------------------------------------------
City | CAMILLUS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-432-4900
-----------------------------------------------------
Fax | 315-488-2397
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 510
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13214-0510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-703-3480
-----------------------------------------------------
Fax | 315-703-3481
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | ROBERT L. TISO
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 315-552-6700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------