Healthcare Provider Details

I. General information

NPI: 1720228851
Provider Name (Legal Business Name): JEREMIAH LEE MARTIN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 COLLEGE DR
MOUNT CARMEL IL
62863-2638
US

IV. Provider business mailing address

323 E 5TH ST
MOUNT CARMEL IL
62863-2123
US

V. Phone/Fax

Practice location:
  • Phone: 618-262-8621
  • Fax:
Mailing address:
  • Phone: 618-450-2480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209007481
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: