Healthcare Provider Details

I. General information

NPI: 1316384795
Provider Name (Legal Business Name): FORERUNNER ANESTHESIA LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2013
Last Update Date: 05/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 BROADWAY SUITE 100W
MERRILLVILLE IN
46410-7040
US

IV. Provider business mailing address

825 N SHERIDAN RD
LAKE FOREST IL
60045-2226
US

V. Phone/Fax

Practice location:
  • Phone: 847-309-9896
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: ARISTEIDIE M DIVERIS
Title or Position: PRESIDENT
Credential: MD
Phone: 847-309-9896