Provider Demographics
NPI:1346281763
Name:BERGBOWER, CAROL J (CRNA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:J
Last Name:BERGBOWER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:J
Other - Last Name:BERGBOWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1000 N ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-1114
Mailing Address - Country:US
Mailing Address - Phone:618-544-3131
Mailing Address - Fax:618-546-2614
Practice Address - Street 1:1000 N ALLEN ST
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1114
Practice Address - Country:US
Practice Address - Phone:618-544-3131
Practice Address - Fax:618-546-2614
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041212985367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00042146OtherRR MEDICARE PIN
IL041212985OtherSTATE LICENSE
IL200009980OtherIRS TAX ID
ILDA2630OtherRR MEDICARE GROUP
IL01732004OtherBC/BS
IL020354300OtherBLACK LUNG
IL540347OtherHEALTHLINK
IL01732004OtherBC/BS
ILP00042146OtherRR MEDICARE PIN