MEDICARE: EILEEN BOETEL CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	28078166A	IN
2	367500000X	Certified Registered Nurse Anesthetist	209.005883	IL
3	367500000X	Certified Registered Nurse Anesthetist	17767330	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000610944	OTHER	IN	ANTHEM PROVIDER NUMBER

General Provider Information

NPI Number	:	1407803265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EILEEN BOETEL CRNA

Provider Business Mailing Address
First Line	:	552 FLEETWOOD DR N
Second Line	:
City	:	VALPARAISO
State	:	IN
Zip	:	46385-6806
Country	:	US
Telephone Number	:	219-929-6982
Fax Number	:	219-464-7221

Provider Business Practice Location Address
First Line	:	18221 TORRENCE AVE
Second Line	:
City	:	LANSING
State	:	IL
Zip	:	60438-2870
Country	:	US
Telephone Number	:	708-895-9450
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	05/20/2013

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Directions to “ EILEEN BOETEL CRNA” Practice Location

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