Healthcare Provider Details

I. General information

NPI: 1225032816
Provider Name (Legal Business Name): EARL GENE DRAVES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 SPRING ST
RED BUD IL
62278-1105
US

IV. Provider business mailing address

325 SPRING ST
RED BUD IL
62278-1105
US

V. Phone/Fax

Practice location:
  • Phone: 618-282-3831
  • Fax: 618-282-1919
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: