Basic Information
| Provider Information | |||||||||
| NPI: | 1225542830 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROSSROADS ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 S MICHIGAN AVE APT 802 | ||||||||
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| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606053268 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 815 PASQUINELLI DR | ||||||||
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| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605591276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306542515 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2017 | ||||||||
| LastUpdateDate: | 11/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | MARRI | ||||||||
| AuthorizedOfficialFirstName: | RAGHU SHANTAN | ||||||||
| AuthorizedOfficialMiddleName: | REDDY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6307764711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.