Healthcare Provider Details

I. General information

NPI: 1649516410
Provider Name (Legal Business Name): RANDY R POMAR CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2012
Last Update Date: 12/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 ELISHA AVE
ZION IL
60099-2676
US

IV. Provider business mailing address

2520 ELISHA AVE
ZION IL
60099-2676
US

V. Phone/Fax

Practice location:
  • Phone: 847-872-6259
  • Fax:
Mailing address:
  • Phone: 847-872-6259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.010072
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: