Provider Demographics
NPI:1578673828
Name:GRAND OAKS ANESTHESIA PC
Entity Type:Organization
Organization Name:GRAND OAKS ANESTHESIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:H
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-549-1609
Mailing Address - Street 1:P.O. BOX 6329
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-6329
Mailing Address - Country:US
Mailing Address - Phone:847-549-1609
Mailing Address - Fax:847-549-1646
Practice Address - Street 1:1800 HOLLISTER DR
Practice Address - Street 2:#202
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5263
Practice Address - Country:US
Practice Address - Phone:847-549-1609
Practice Address - Fax:847-549-1646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618093174400000X
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213447Medicare UPIN