Healthcare Provider Details

I. General information

NPI: 1558306480
Provider Name (Legal Business Name): ASSOCIATED ANESTHESIOLOGISTS, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6742 N FROSTWOOD PKWY
PEORIA IL
61615-2402
US

IV. Provider business mailing address

6742 N FROSTWOOD PKWY
PEORIA IL
61615-2402
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-5393
  • Fax: 309-668-9998
Mailing address:
  • Phone: 309-692-5393
  • Fax: 309-683-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY HELEN BOWMAN
Title or Position: INFORMATION SERVICES
Credential:
Phone: 309-692-5393