Basic Information
Provider Information | |||||||||
NPI: | 1033644653 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARRI ANESTHETICS LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1121 LAKE COOK RD STE M | ||||||||
Address2: |   | ||||||||
City: | DEERFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 600155234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8479454550 | ||||||||
FaxNumber: | 8479488103 | ||||||||
Practice Location | |||||||||
Address1: | 815 PASQUINELLI DR | ||||||||
Address2: |   | ||||||||
City: | WESTMONT | ||||||||
State: | IL | ||||||||
PostalCode: | 605591276 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6306542515 | ||||||||
FaxNumber: | 6306549344 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2017 | ||||||||
LastUpdateDate: | 09/22/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARRI | ||||||||
AuthorizedOfficialFirstName: | RAGHU SHANTAN | ||||||||
AuthorizedOfficialMiddleName: | REDDY | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6307764711 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 207L00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.