MEDICARE: HELEN TEWOLDE FREMICHAEL 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	209010466	IL
2	163W00000X	Registered Nurse	0001201189	VA
3	367500000X	Certified Registered Nurse Anesthetist	0024195893	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	041410764	OTHER	IL	STATE LICENSE

General Provider Information

NPI Number	:	1740621572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HELEN TEWOLDE FREMICHAEL CRNA

Provider Business Mailing Address
First Line	:	12251 S 80TH AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1290
Country	:	US
Telephone Number	:	708-923-4000
Fax Number	:	708-923-8848

Provider Business Practice Location Address
First Line	:	12251 S 80TH AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1290
Country	:	US
Telephone Number	:	708-923-4000
Fax Number	:	708-923-8848

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

Provider Enumeration Date	:	07/09/2013
Last Update Date	:	02/09/2026

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