MEDICARE: BRIDGFORD NURSE ANESTHESIA SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	79515	IL

General Provider Information

NPI Number	:	1659823342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGFORD NURSE ANESTHESIA SERVICES

Provider Business Mailing Address
First Line	:	1130 S MICHIGAN AVE
Second Line	:	#3709
City	:	CHICAGO
State	:	IL
Zip	:	60605-2521
Country	:	US
Telephone Number	:	630-414-3108
Fax Number	:	630-225-5207

Provider Business Practice Location Address
First Line	:	1130 S MICHIGAN AVE
Second Line	:	#3709
City	:	CHICAGO
State	:	IL
Zip	:	60605-2521
Country	:	US
Telephone Number	:	630-414-3108
Fax Number	:	630-225-5207

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHRISTY L BRIDGFORD
Credential	:	CRNA
Telephone Number	:	630-414-3108

Provider Enumeration Date	:	10/27/2016
Last Update Date	:	10/27/2016

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