Healthcare Provider Details

I. General information

NPI: 1962404442
Provider Name (Legal Business Name): DANIEL W. BORVAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 W DIVISION ST
CHICAGO IL
60622-3043
US

IV. Provider business mailing address

328 E LINCOLN HWY
NEW LENOX IL
60451-1849
US

V. Phone/Fax

Practice location:
  • Phone: 312-770-2000
  • Fax:
Mailing address:
  • Phone: 815-462-8470
  • Fax: 815-462-8471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209003563
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: