Basic Information
| Provider Information | |||||||||
| NPI: | 1790963114 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST ANESTHESIA CONSULTANTS, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 MAIN ST | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616021267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096718749 | ||||||||
| FaxNumber: | 3096718740 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615544936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093471151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2008 | ||||||||
| LastUpdateDate: | 09/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | ADRIENNE | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3096718749 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036109114 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 216289 | 01 | IL | MEDICARE GROUP NUMBER | OTHER |