Healthcare Provider Details

I. General information

NPI: 1063128049
Provider Name (Legal Business Name): PRINCIPLE ANESTHESIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 MAXINE DR
MORTON IL
61550-2495
US

IV. Provider business mailing address

PO BOX 631
LAKE FOREST IL
60045-0631
US

V. Phone/Fax

Practice location:
  • Phone: 309-495-4520
  • Fax:
Mailing address:
  • Phone: 847-615-2858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MICHAEL KEEDY
Title or Position: OWNER
Credential: CRNA
Phone: 309-267-5510