MEDICARE: MR. LARRY J KOTEWA 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		IL

General Provider Information

NPI Number	:	1942278130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LARRY J KOTEWA CRNA

Provider Business Mailing Address
First Line	:	124 W WHITEHALL CT
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61614-3032
Country	:	US
Telephone Number	:	309-691-2607
Fax Number	:	309-683-1003

Provider Business Practice Location Address
First Line	:	124 W WHITEHALL CT
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61614-3032
Country	:	US
Telephone Number	:	309-691-2607
Fax Number	:	309-683-1003

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/08/2007

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