Provider Demographics
NPI:1821006057
Name:ANDERSON, THERESIA M (CRNA)
Entity Type:Individual
Prefix:
First Name:THERESIA
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:THERESIA
Other - Middle Name:M
Other - Last Name:GIDCUMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:300 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4200
Mailing Address - Country:US
Mailing Address - Phone:630-208-4060
Mailing Address - Fax:630-208-4401
Practice Address - Street 1:300 RANDALL RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4200
Practice Address - Country:US
Practice Address - Phone:630-208-4060
Practice Address - Fax:630-208-4401
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005217367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1032044OtherBCBS
IL1032044OtherBCBS
ILK14452Medicare PIN
IL206661Medicare PIN