Healthcare Provider Details

I. General information

NPI: 1790143683
Provider Name (Legal Business Name): MIDWEST MOBILE ANESTHESIA CONSULTANTS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2016
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W WALNUT ST
CANTON IL
61520-2444
US

IV. Provider business mailing address

4128 W STONEWATER DR
PEORIA IL
61615-8852
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-6572
  • Fax:
Mailing address:
  • Phone: 309-692-6572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number042620313
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number042620313
License Number StateIL

VIII. Authorized Official

Name: DR. ADRIENNE YVETTE WILLIAMS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 309-453-1379