Basic Information
| Provider Information | |||||||||
| NPI: | 1740599752 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHSIDE ANESTHESIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9315 RIDGEWAY AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602031308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733830776 | ||||||||
| FaxNumber: | 8478595852 | ||||||||
| Practice Location | |||||||||
| Address1: | 9315 RIDGEWAY AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602031308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733830776 | ||||||||
| FaxNumber: | 8478595852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2010 | ||||||||
| LastUpdateDate: | 05/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | FORSTER | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEAD CRNA | ||||||||
| AuthorizedOfficialTelephone: | 7733830776 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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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 | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.