Healthcare Provider Details

I. General information

NPI: 1467636563
Provider Name (Legal Business Name): TIMOTHY WILLIAM KANE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 07/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N WALL ST DEPT OF ANESTHESIA
KANKAKEE IL
60901-2901
US

IV. Provider business mailing address

68 S SERVICE RD SUITE 350
MELVILLE NY
11747-2354
US

V. Phone/Fax

Practice location:
  • Phone: 815-933-1671
  • Fax:
Mailing address:
  • Phone: 516-945-3156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209006913
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: