Healthcare Provider Details

I. General information

NPI: 1275653883
Provider Name (Legal Business Name): FRED J COOK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W. UNIVERSITY AVENUE ANESTHESIOLOGY
URBANA IL
61801
US

IV. Provider business mailing address

P.O. BOX 6002
URBANA IL
61803-6002
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3141
  • Fax: 217-383-3265
Mailing address:
  • Phone: 217-326-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209000157
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: