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General NPI Number Information
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NPI Number | 1407984255
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Entity Type | Organization
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Legal Business Name | WINE ANESTHESIA, LLC
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Dates
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Enumeration Date | 03/02/2007
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Last Update Date | 04/23/2021
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Provider Practice Location Address
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Address Line | 129 SLOSSON AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10314-2522
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Country | US
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Telephone | 718-720-5928
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 120223
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City | STATEN ISLAND
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State | NY
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Zip | 10312-0223
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Country | US
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Telephone | 718-663-9251
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | LAWRENCE WINE
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Credential | MD
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Telephone | 718-663-9251
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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