Provider Demographics
NPI:1255706818
Name:SPECKER, JOSEPH IV (CRNA)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:SPECKER
Suffix:IV
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 1:1616 W MAIN ST STE 508
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1146
Mailing Address - Country:US
Mailing Address - Phone:228-861-1192
Mailing Address - Fax:618-997-1122
Practice Address - Street 1:3333 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5884
Practice Address - Country:US
Practice Address - Phone:228-861-1192
Practice Address - Fax:618-997-1122
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013614367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered