Healthcare Provider Details

I. General information

NPI: 1568461523
Provider Name (Legal Business Name): LARRY DUANE RAWLINGS C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MAPLE SUMMIT RD
JERSEYVILLE IL
62052-2028
US

IV. Provider business mailing address

301 HAWBROOK PL
JERSEYVILLE IL
62052-1018
US

V. Phone/Fax

Practice location:
  • Phone: 618-498-8420
  • Fax:
Mailing address:
  • Phone: 618-498-9014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN 041-167880
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-000763
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: