Basic Information
| Provider Information | |||||||||
| NPI: | 1043385859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DALEY | ||||||||
| FirstName: | GREG | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W PARK STREET | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | 2173834752 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173833141 | ||||||||
| FaxNumber: | 2173833265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 03/06/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 209005469 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 6447860011 | 05 | IL | MEDICAID |