Healthcare Provider Details

I. General information

NPI: 1326057423
Provider Name (Legal Business Name): DAVID PETER RAKEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 WILSHIRE DR
MOUNT VERNON IL
62864-2743
US

IV. Provider business mailing address

14 FAIRWAY DR
MOUNT VERNON IL
62864-2621
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-4150
  • Fax: 618-244-1696
Mailing address:
  • Phone: 618-244-2509
  • Fax: 618-244-1696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-0011244
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: