Provider Demographics
NPI:1023256203
Name:BLACK DOG ANESTHESIA PLLC
Entity type:Organization
Organization Name:BLACK DOG ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ROSALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-587-9208
Mailing Address - Street 1:100 W UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:ALFRED
Mailing Address - State:NY
Mailing Address - Zip Code:14802-1134
Mailing Address - Country:US
Mailing Address - Phone:607-587-9208
Mailing Address - Fax:
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569-1025
Practice Address - Country:US
Practice Address - Phone:585-786-1222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171396207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty