Healthcare Provider Details

I. General information

NPI: 1659395663
Provider Name (Legal Business Name): DAVID MATTHEW GRAZAITIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 E COURT ST
PARIS IL
61944-2460
US

IV. Provider business mailing address

700 E WOOD ST
PARIS IL
61944-1959
US

V. Phone/Fax

Practice location:
  • Phone: 217-465-4141
  • Fax: 217-463-2769
Mailing address:
  • Phone: 217-466-6695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-002477
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041-217094
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number209-002477
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: