Healthcare Provider Details

I. General information

NPI: 1053583716
Provider Name (Legal Business Name): AMBULATORY ANESTHESIOLOGY, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 IRELAND GROVE RD
BLOOMINGTON IL
61704
US

IV. Provider business mailing address

PO BOX 489
BLOOMINGTON IL
61702-0489
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-0101
  • Fax:
Mailing address:
  • Phone: 309-585-0283
  • Fax: 309-585-0283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. MARK LANZEROTTE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 309-585-0283