Healthcare Provider Details

I. General information

NPI: 1821006057
Provider Name (Legal Business Name): THERESIA M ANDERSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESIA M GIDCUMB CRNA

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 RANDALL RD
GENEVA IL
60134-4200
US

IV. Provider business mailing address

300 RANDALL RD
GENEVA IL
60134-4200
US

V. Phone/Fax

Practice location:
  • Phone: 630-208-4060
  • Fax: 630-208-4401
Mailing address:
  • Phone: 630-208-4060
  • Fax: 630-208-4401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209005217
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: