Healthcare Provider Details

I. General information

NPI: 1932185469
Provider Name (Legal Business Name): TIMOTHY O'CONNOR CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 MADISON AVE
GRANITE CITY IL
62040-4701
US

IV. Provider business mailing address

PO BOX 503734
SAINT LOUIS MO
63150-0001
US

V. Phone/Fax

Practice location:
  • Phone: 660-826-5960
  • Fax: 660-826-4852
Mailing address:
  • Phone: 660-826-5960
  • Fax: 660-826-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209005367
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: