Healthcare Provider Details

I. General information

NPI: 1902503055
Provider Name (Legal Business Name): MR. ELISHA JAMES KRONCKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 N RANDALL RD STE AIP
ELGIN IL
60123-2300
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 800-655-2656
  • Fax: 412-822-7411
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041374043
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209027231
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number209-027231
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: