Basic Information
Provider Information | |||||||||
NPI: | 1376677187 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOLDSTEIN FELT | ||||||||
FirstName: | TRACEY | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FELT | ||||||||
OtherFirstName: | TRACEY | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | APN-CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2650 RIDGE AVE | ||||||||
Address2: | EVANSTON HOSPITAL | ||||||||
City: | EVANSTON | ||||||||
State: | IL | ||||||||
PostalCode: | 602011718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475701206 | ||||||||
FaxNumber: | 8475701248 | ||||||||
Practice Location | |||||||||
Address1: | 2650 RIDGE AVE | ||||||||
Address2: | ANESTHESIOLOGY, ROOM 3905 | ||||||||
City: | EVANSTON | ||||||||
State: | IL | ||||||||
PostalCode: | 60201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475702760 | ||||||||
FaxNumber: | 8475702921 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2007 | ||||||||
LastUpdateDate: | 08/22/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 041-320747 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 041-320747 | 01 | IL | IL STATE LIC | OTHER |