Basic Information
| Provider Information | |||||||||
| NPI: | 1356364293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KASHMAR | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KASHMAR | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 925 SHERWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKE BLUFF | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600442203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476152200 | ||||||||
| FaxNumber: | 8476152858 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 S MILWAUKEE AVE | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600483204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473622900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 12/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 041259305 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 430014089 | 01 | IL | RAILROAD MEDICARE | OTHER |