MEDICARE: MRS. LESA RENEE' SEALES AA-C

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	367H00000X	Anesthesiologist Assistant	2009028903	MO
2	367H00000X	Anesthesiologist Assistant	161D
3	163WP0000X	Pain Management Registered Nurse	AA NOT LIC. BY STATE	IL

General Provider Information

NPI Number	:	1811969892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LESA RENEE' SEALES AA-C

Provider Business Mailing Address
First Line	:	3215 EXECUTIVE PARK DR.
Second Line	:	HSHS MEDICAL GROUP
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703
Country	:	US
Telephone Number	:	618-234-2120
Fax Number	:	618-641-5410

Provider Business Practice Location Address
First Line	:	211 S. 3RD ST.
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221
Country	:	US
Telephone Number	:	618-234-2120
Fax Number	:	618-641-5410

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	07/27/2022

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