Healthcare Provider Details

I. General information

NPI: 1366098162
Provider Name (Legal Business Name): PRINCIPAL ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 08/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1928 45TH ST
MUNSTER IN
46321-3917
US

IV. Provider business mailing address

PO BOX 70
LAKE FOREST IL
60045-0070
US

V. Phone/Fax

Practice location:
  • Phone: 219-476-7246
  • Fax:
Mailing address:
  • Phone: 800-444-6110
  • Fax: 847-615-2858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: RONI AIZIGOV
Title or Position: OWNER
Credential: CRNA
Phone: 847-615-2200