Healthcare Provider Details

I. General information

NPI: 1962459669
Provider Name (Legal Business Name): ILLINOIS ANESTHESIA ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N WALL ST
KANKAKEE IL
60901-2901
US

IV. Provider business mailing address

PO BOX 550374
TAMPA FL
33655-0374
US

V. Phone/Fax

Practice location:
  • Phone: 815-933-1671
  • Fax:
Mailing address:
  • Phone: 847-615-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN MITCHELL
Title or Position: PRESIDENT
Credential: MD
Phone: 800-444-6110