Provider Demographics
NPI:1245208685
Name:ANESTHESIA SPECIALTIES ALLIANCE, S.C.
Entity Type:Organization
Organization Name:ANESTHESIA SPECIALTIES ALLIANCE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:HARVEY
Authorized Official - Last Name:IFFT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-360-2600
Mailing Address - Street 1:7309 N. KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-360-2600
Mailing Address - Fax:309-683-1003
Practice Address - Street 1:7309 N. KNOXVILLE AVE.
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-360-2600
Practice Address - Fax:309-683-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042617566207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL200275Medicare ID - Type UnspecifiedPHYSICIANS NUMBER
IL201474Medicare ID - Type UnspecifiedCRNA'S MEDICARE NUMBER