Healthcare Provider Details

I. General information

NPI: 1164463899
Provider Name (Legal Business Name): JERRIE J POSTHUMUS C.R.N.A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19624 GOVERNORS HWY
FLOSSMOOR IL
60422-2077
US

IV. Provider business mailing address

19624 GOVERNORS HWY
FLOSSMOOR IL
60422-2077
US

V. Phone/Fax

Practice location:
  • Phone: 708-798-5838
  • Fax: 708-798-5865
Mailing address:
  • Phone: 708-798-5838
  • Fax: 708-798-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.002718
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: