Healthcare Provider Details

I. General information

NPI: 1134993306
Provider Name (Legal Business Name): TREVOR MARTIN ROGERS DNP CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 11/08/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

3259 N KENMORE AVE
CHICAGO IL
60657-3306
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.028700
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: