Provider Demographics
NPI:1922010933
Name:AGNICH, MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:AGNICH
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:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-0367
Mailing Address - Country:US
Mailing Address - Phone:815-320-3086
Mailing Address - Fax:815-464-1767
Practice Address - Street 1:1210 CROWN FOX LN
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1205
Practice Address - Country:US
Practice Address - Phone:815-320-3086
Practice Address - Fax:815-464-1767
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000590207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL430075461OtherRAILROAD MEDICARE
IL9932061OtherBLUE CROSS BLUE SHIELD
ILS49630Medicare UPIN
ILL91897Medicare PIN
ILK48277Medicare PIN
ILK09413Medicare PIN