Healthcare Provider Details

I. General information

NPI: 1316399967
Provider Name (Legal Business Name): CLINICAL COLLEAGUES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 N KELLOGG ST
GALESBURG IL
61401-2807
US

IV. Provider business mailing address

PO BOX 824246
PHILADELPHIA PA
19182-4246
US

V. Phone/Fax

Practice location:
  • Phone: 800-494-3964
  • Fax: 954-570-0317
Mailing address:
  • Phone: 954-570-0337
  • Fax: 954-570-0317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL GERDES
Title or Position: MANAGING PARTNER
Credential:
Phone: 800-494-3964