Provider Demographics
NPI:1992003636
Name:COLLINS AMBULATORY ANESTHESIA SERVICES SC
Entity Type:Organization
Organization Name:COLLINS AMBULATORY ANESTHESIA SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-973-5189
Mailing Address - Street 1:106 FRIARS LN
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3876
Mailing Address - Country:US
Mailing Address - Phone:618-973-5189
Mailing Address - Fax:
Practice Address - Street 1:106 FRIARS LN
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3876
Practice Address - Country:US
Practice Address - Phone:618-973-5189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079652207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1770804452Medicaid
IL1770804452Medicaid