Healthcare Provider Details

I. General information

NPI: 1649879842
Provider Name (Legal Business Name): JOHN HURLEY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 03/07/2024
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MACARTHUR BLVD
MUNSTER IN
46321-2959
US

IV. Provider business mailing address

11147 S FAIRFIELD AVE
CHICAGO IL
60655-1929
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28255558A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209024977
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: