Provider Demographics
NPI:1265925218
Name:SENTINEL ANESTHESIA OF ILLINOIS, PC
Entity type:Organization
Organization Name:SENTINEL ANESTHESIA OF ILLINOIS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:800-444-6110
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-0570
Mailing Address - Country:US
Mailing Address - Phone:800-444-6110
Mailing Address - Fax:
Practice Address - Street 1:7340 W COLLEGE DR FL 1
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463
Practice Address - Country:US
Practice Address - Phone:708-361-3233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty