Healthcare Provider Details

I. General information

NPI: 1679258388
Provider Name (Legal Business Name): ELITE ANESTHESIA PROVIDERS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19110 DARVIN DR STE A
MOKENA IL
60448-8683
US

IV. Provider business mailing address

PO BOX 70
LAKE FOREST IL
60045-0070
US

V. Phone/Fax

Practice location:
  • Phone: 708-478-8889
  • Fax: 708-478-8507
Mailing address:
  • Phone: 800-444-6110
  • 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: MARK TOMCZAK
Title or Position: PRESIDENT
Credential: CRNA
Phone: 708-431-0160