Healthcare Provider Details

I. General information

NPI: 1134951312
Provider Name (Legal Business Name): ALHAGI SALIFU JAITEH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

IV. Provider business mailing address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

V. Phone/Fax

Practice location:
  • Phone: 217-223-8400
  • Fax: 217-223-9552
Mailing address:
  • Phone: 217-223-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209035855
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: