Provider Demographics
NPI:1023186517
Name:BUREAU VALLEY ANESTHESIA GROUP, INC.
Entity Type:Organization
Organization Name:BUREAU VALLEY ANESTHESIA GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEOFIL
Authorized Official - Middle Name:L
Authorized Official - Last Name:ORTEZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-875-6001
Mailing Address - Street 1:130 N MAIN ST
Mailing Address - Street 2:PO BOX 372
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-1785
Mailing Address - Country:US
Mailing Address - Phone:815-875-6001
Mailing Address - Fax:815-875-3612
Practice Address - Street 1:130 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-1785
Practice Address - Country:US
Practice Address - Phone:815-875-6001
Practice Address - Fax:815-875-3612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054242207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1023186517OtherNPI