Healthcare Provider Details

I. General information

NPI: 1609136746
Provider Name (Legal Business Name): KYLE HARDIMAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N ALLEN ST
ROBINSON IL
62454-1114
US

IV. Provider business mailing address

1000 N ALLEN ST
ROBINSON IL
62454-1114
US

V. Phone/Fax

Practice location:
  • Phone: 618-544-3131
  • Fax: 618-546-2630
Mailing address:
  • Phone: 618-544-3131
  • Fax: 618-546-2630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041-359377
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: