Healthcare Provider Details

I. General information

NPI: 1760593131
Provider Name (Legal Business Name): ROBINSON J OMOTOLA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PLEASANT AVE
CENTRALIA IL
62801-3056
US

IV. Provider business mailing address

PO BOX 917756
ORLANDO FL
32891-7756
US

V. Phone/Fax

Practice location:
  • Phone: 618-436-5461
  • Fax:
Mailing address:
  • Phone: 352-867-8898
  • Fax: 352-732-6282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP2030632
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: