=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184997488
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LATHAM ANESTHESIOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2012
-----------------------------------------------------
Last Update Date | 04/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1072 TROY SCHENECTADY RD SUITE 303
-----------------------------------------------------
City | LATHAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12110-1025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-713-4484
-----------------------------------------------------
Fax | 518-713-4486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13 CENTURY HILL DR
-----------------------------------------------------
City | LATHAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12110-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-713-4484
-----------------------------------------------------
Fax | 518-713-4486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAUL S SOCCIO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 518-713-4484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 238532
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------