=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780001354
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTCLAIR ANESTHESIA GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2014
-----------------------------------------------------
Last Update Date | 03/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 393 BLOOMFIELD AVE
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-3741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-746-1500
-----------------------------------------------------
Fax | 973-746-0955
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 393 BLOOMFIELD AVE
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-3741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-746-1500
-----------------------------------------------------
Fax | 973-746-0955
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. NICHOLAS V CAMPANELLA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 973-746-1500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------