Healthcare Provider Details

I. General information

NPI: 1659823342
Provider Name (Legal Business Name): BRIDGFORD NURSE ANESTHESIA SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 S MICHIGAN AVE #3709
CHICAGO IL
60605-2521
US

IV. Provider business mailing address

1130 S MICHIGAN AVE #3709
CHICAGO IL
60605-2521
US

V. Phone/Fax

Practice location:
  • Phone: 630-414-3108
  • Fax: 630-225-5207
Mailing address:
  • Phone: 630-414-3108
  • Fax: 630-225-5207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number79515
License Number StateIL

VIII. Authorized Official

Name: CHRISTY L BRIDGFORD
Title or Position: PRESIDENT
Credential: CRNA
Phone: 630-414-3108