Healthcare Provider Details

I. General information

NPI: 1265829113
Provider Name (Legal Business Name): MATTHEW FARCUS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2015
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 WOODLAKE BLVD 1304
GURNEE IL
60031-6714
US

IV. Provider business mailing address

1666 KIRSTEN LEE DR
WILMINGTON IL
60481-4100
US

V. Phone/Fax

Practice location:
  • Phone: 815-791-6084
  • Fax:
Mailing address:
  • Phone: 815-791-6084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041382727
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number193394
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.012934
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: