Provider Demographics
NPI:1023207909
Name:AESTHETIC ANESTHESIA, LLC
Entity Type:Organization
Organization Name:AESTHETIC ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARA
Authorized Official - Middle Name:G
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:847-269-9086
Mailing Address - Street 1:1912 PALMGREN DR
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-4216
Mailing Address - Country:US
Mailing Address - Phone:847-269-9086
Mailing Address - Fax:
Practice Address - Street 1:1912 PALMGREN DR
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-4216
Practice Address - Country:US
Practice Address - Phone:847-269-9086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041274227261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical