Healthcare Provider Details

I. General information

NPI: 1437129335
Provider Name (Legal Business Name): JOHN MARC PROVENZANO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

1042 RIVEROAKS CT
RANDLEMAN NC
27317-7987
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-6700
  • Fax:
Mailing address:
  • Phone: 630-607-9949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209001255
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number6183
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: