Basic Information
| Provider Information | |||||||||
| NPI: | 1265925218 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SENTINEL ANESTHESIA OF ILLINOIS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 570 | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600450570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004446110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7340 W COLLEGE DR FL 1 | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083613233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2018 | ||||||||
| LastUpdateDate: | 07/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8004446110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.