Provider Demographics
NPI:1669454740
Name:SWIFT, THERESA MARIE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:SWIFT
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 1:2001 N MATTIS AVE UNIT 7230
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61826-0991
Mailing Address - Country:US
Mailing Address - Phone:217-840-1419
Mailing Address - Fax:
Practice Address - Street 1:2001 N MATTIS AVE UNIT 7230
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61826-0991
Practice Address - Country:US
Practice Address - Phone:217-840-1419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000388367500000X
IN28150300A163W00000X
FL9271688163W00000X
TX574749163W00000X
KY3007658163W00000X
FLARNP9271688367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371390028001OtherTRICARE GROUP ID NO.
IL216564000OtherWORKMAN'S COMP GROUP ID
IL430068235OtherRR MEDICARE PIN
ILCG3273OtherRR MEDICARE GROUP ID NO.
FLGV765YOtherMEDICARE PTAN
IL09223524OtherBC/BS GROUP ID NO.
FL008321200Medicaid
IL561020Medicare ID - Type UnspecifiedGROUP IDENTIFICATION NO.
IL216564000OtherWORKMAN'S COMP GROUP ID