Provider Demographics
NPI:1629075775
Name:MCBRIDE, ROBERTA SUZANNE (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:SUZANNE
Last Name:MCBRIDE
Suffix:
Gender:F
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:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:IL
Mailing Address - Zip Code:61914-0425
Mailing Address - Country:US
Mailing Address - Phone:217-665-3609
Mailing Address - Fax:
Practice Address - Street 1:1800 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3810
Practice Address - Country:US
Practice Address - Phone:217-464-2729
Practice Address - Fax:217-464-1693
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205287Medicare ID - Type Unspecified