Healthcare Provider Details

I. General information

NPI: 1588651566
Provider Name (Legal Business Name): TIMOTHY JAMES SAMOLITIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 N. STATE ROUTE 91 SUITE 250
PEORIA IL
61615
US

IV. Provider business mailing address

8600 N. STATE ROUTE 91 SUITE 250
PEORIA IL
61615
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-5394
  • Fax: 309-692-2538
Mailing address:
  • Phone: 309-692-5394
  • Fax: 309-692-2538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209005907
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR143228
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: