Provider Demographics
NPI:1942569843
Name:INTRANERVE LLC
Entity Type:Organization
Organization Name:INTRANERVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR. OF OPERATONS MIDWEST.
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:KOSTREVA
Authorized Official - Suffix:
Authorized Official - Credentials:BS CNIM
Authorized Official - Phone:331-330-3336
Mailing Address - Street 1:2210 ABBEYWOOD DR STE A
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-3384
Mailing Address - Country:US
Mailing Address - Phone:331-330-3336
Mailing Address - Fax:
Practice Address - Street 1:2210 ABBEYWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-3384
Practice Address - Country:US
Practice Address - Phone:331-330-3336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246ZE0600X246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Single Specialty