Provider Demographics
NPI:1033206024
Name:EDWARD J ALLISON PSC
Entity Type:Organization
Organization Name:EDWARD J ALLISON PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:941-747-2830
Mailing Address - Street 1:724 E 125TH ROAD
Mailing Address - Street 2:
Mailing Address - City:KANSAS
Mailing Address - State:IL
Mailing Address - Zip Code:61933
Mailing Address - Country:US
Mailing Address - Phone:941-747-2830
Mailing Address - Fax:941-747-6170
Practice Address - Street 1:227 E MCCALLISTER DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4248
Practice Address - Country:US
Practice Address - Phone:765-832-7372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200514680Medicaid
IL=========-34209-01Medicaid