Healthcare Provider Details

I. General information

NPI: 1629009840
Provider Name (Legal Business Name): VINCENT J MILAZZO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE ANESTHESIA DEPARTMENT
BERWYN IL
60402
US

IV. Provider business mailing address

3998 FAIR RIDGE DR STE 300
FAIRFAX VA
22033-2921
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-3667
  • Fax:
Mailing address:
  • Phone: 703-295-9360
  • Fax: 703-766-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209000249
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: