Healthcare Provider Details

I. General information

NPI: 1235764218
Provider Name (Legal Business Name): COURTNEY J HARRIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT ELIZABETH BLVD
O FALLON IL
62269-1099
US

IV. Provider business mailing address

319 N OAKCREST AVE
DECATUR IL
62522-1812
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-2120
  • Fax: 618-641-5810
Mailing address:
  • Phone: 314-616-5191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.020870
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: