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NPI Code Detail

MEDICARE: ROBERTA SUZANNE MCBRIDE CRNA

MEDICARE: ROBERTA SUZANNE MCBRIDE 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
1367500000XCertified Registered Nurse AnesthetistIL

General Provider Information

NPI Number : 1629075775
Entity Type Code : Individual
Provider Name (Legal Business Name) : ROBERTA SUZANNE MCBRIDE CRNA
Provider Business Mailing Address
First Line : PO BOX 425
Second Line :
City : BETHANY
State : IL
Zip : 61914-0425
Country : US
Telephone Number : 217-665-3609
Fax Number :
Provider Business Practice Location Address
First Line : 1800 E LAKE SHORE DR
Second Line :
City : DECATUR
State : IL
Zip : 62521-3810
Country : US
Telephone Number : 217-464-2729
Fax Number : 217-464-1693
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/05/2005
Last Update Date : 07/08/2007

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