Basic Information
| Provider Information | |||||||||
| NPI: | 1194155671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUDOR | ||||||||
| FirstName: | ALICE | ||||||||
| MiddleName: | ELENA | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29373 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473905900 | ||||||||
| FaxNumber: | 8473904757 | ||||||||
| Practice Location | |||||||||
| Address1: | 3134 N CLARK ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606574414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737664949 | ||||||||
| FaxNumber: | 3127664909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2013 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 209.010958 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN195845 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 003145166A | 05 | GA | MEDICAID |