Basic Information
Provider Information
NPI: 1962512335
EntityType: 2
ReplacementNPI:  
OrganizationName: AMERICAN ANESTHESIOLOGY ASSOCIATES OF ILLINOIS, S.C.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: ASSOCIATED ANESTHESIOLOGISTS OF JOLIET, SC
OtherOrganizationType: 4
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 535775
Address2:  
City: ATLANTA
State: GA
PostalCode: 303535510
CountryCode: US
TelephoneNumber: 8002433839
FaxNumber: 8446361410
Practice Location
Address1: 19627 S LA GRANGE RD
Address2:  
City: MOKENA
State: IL
PostalCode: 604489360
CountryCode: US
TelephoneNumber: 8002433839
FaxNumber: 8446361410
Other Information
ProviderEnumerationDate: 08/30/2006
LastUpdateDate: 08/06/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: WALSH
AuthorizedOfficialFirstName: MATTHEW
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: VICE PRESIDENT
AuthorizedOfficialTelephone: 8002433839
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate: 08/06/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000X  N193200000X MULTI-SPECIALTY GROUPOther Service ProvidersSpecialist 
207L00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansAnesthesiology 

No ID Information.


Home