Basic Information
| Provider Information | |||||||||
| NPI: | 1013293547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLSEN | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | PHILIP | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1262 W PRATT BLVD | ||||||||
| Address2: | APT 3 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606264382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477694836 | ||||||||
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| Practice Location | |||||||||
| Address1: | 251 E HURON ST | ||||||||
| Address2: | FEINBERG 5-704 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129268369 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2011 | ||||||||
| LastUpdateDate: | 10/28/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 041.356505 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.