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General NPI Number Information
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NPI Number | 1801047865
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Entity Type | Organization
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Legal Business Name | JERSEY COUNTY ANESTHESIA GROUP LTD
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Dates
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Enumeration Date | 10/08/2008
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Last Update Date | 10/08/2008
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Provider Practice Location Address
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Address Line | 400 MAPLE SUMMIT RD
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City | JERSEYVILLE
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State | IL
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Zip | 62052-2028
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Country | US
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Telephone | 618-498-9014
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Fax | 618-498-9014
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Provider Business Mailing Address
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Address Line | 301 HAWBROOK PL
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City | JERSEYVILLE
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State | IL
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Zip | 62052-1018
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Country | US
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Telephone | 618-498-9014
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Fax | 618-498-9014
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. LARRY DUANE RAWLINGS
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Credential | CRNA
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Telephone | 618-498-9014
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 060.008358
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License Number State | IL
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