Provider Demographics
NPI:1568417046
Name:BIRKY, DENNIS DAN (CRNA)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:DAN
Last Name:BIRKY
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 1:701 E ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:HOOPESTON
Mailing Address - State:IL
Mailing Address - Zip Code:60942-1801
Mailing Address - Country:US
Mailing Address - Phone:217-283-5531
Mailing Address - Fax:217-283-7981
Practice Address - Street 1:701 E ORANGE ST
Practice Address - Street 2:
Practice Address - City:HOOPESTON
Practice Address - State:IL
Practice Address - Zip Code:60942-1801
Practice Address - Country:US
Practice Address - Phone:217-283-5531
Practice Address - Fax:217-748-6231
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28069877A367500000X
MO125861367500000X
TNAPN0000011571367500000X
IL367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000485518OtherANTHEM PIN NUMBER
IN9447676OtherPHCS PID NUMBER
IN11573787OtherCAQH NUMBER
IN9447676OtherPHCS PID NUMBER
IN11573787OtherCAQH NUMBER
IL794582Medicare PIN