Provider Demographics
NPI:1205838216
Name:DIONISOPOULOS, JAMES A (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:DIONISOPOULOS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KISH HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-4939
Mailing Address - Country:US
Mailing Address - Phone:815-756-1521
Mailing Address - Fax:815-748-8395
Practice Address - Street 1:1 KISH HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4939
Practice Address - Country:US
Practice Address - Phone:815-756-1521
Practice Address - Fax:815-748-8395
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-144402207LP2900X
IL209-000856207LP2900X
IL209.000856367500000X
IL041.144402367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP51955Medicare UPIN
ILL90532Medicare PIN