MEDICARE: CRNA STAT INC

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

General Provider Information

NPI Number	:	1639797525
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRNA STAT INC

Provider Business Mailing Address
First Line	:	4534 S LAKE PARK AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-4510
Country	:	US
Telephone Number	:	312-394-0222
Fax Number	:

Provider Business Practice Location Address
First Line	:	4534 S LAKE PARK AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-4510
Country	:	US
Telephone Number	:	312-394-0222
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	PATRICE HARRELL JOHNSON
Credential	:	CRNA, MS
Telephone Number	:	312-394-0222

Provider Enumeration Date	:	07/08/2020
Last Update Date	:	07/24/2020

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