Healthcare Provider Details

I. General information

NPI: 1689676694
Provider Name (Legal Business Name): CRAIG R MCCLOUD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 BETHANY RD
DEKALB IL
60115-4939
US

IV. Provider business mailing address

6910 S MADISON ST
WILLOW BROOK IL
60527-5504
US

V. Phone/Fax

Practice location:
  • Phone: 815-748-8993
  • Fax:
Mailing address:
  • Phone: 815-748-8993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: