Healthcare Provider Details

I. General information

NPI: 1245661560
Provider Name (Legal Business Name): RESOLUTE ANESTHESIA ILLINOIS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 HAMACHER ST
WATERLOO IL
62298-1568
US

IV. Provider business mailing address

PO BOX 744130
ATLANTA GA
30374-4130
US

V. Phone/Fax

Practice location:
  • Phone: 908-653-9399
  • Fax: 908-653-9305
Mailing address:
  • Phone: 908-653-9399
  • Fax: 908-653-9305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN VAUGHN
Title or Position: OFFICER
Credential:
Phone: 954-838-2371