Provider Demographics
NPI:1750410726
Name:ILLINOIS ANESTHESIA COVERAGE P.C.
Entity type:Organization
Organization Name:ILLINOIS ANESTHESIA COVERAGE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WELLINGHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:217-352-8947
Mailing Address - Street 1:PO BOX 7048
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61826-7048
Mailing Address - Country:US
Mailing Address - Phone:217-352-8947
Mailing Address - Fax:217-352-8947
Practice Address - Street 1:4010 RIVERKNOLL DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-9213
Practice Address - Country:US
Practice Address - Phone:217-352-8947
Practice Address - Fax:217-352-8947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209 001163367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCG3273OtherMEDICARE, RAILROAD
A001OtherTRICARE MILITARY
IL092-253-24OtherBLUE CROSS BLUE SHIELD IL
IN252790Medicare PIN
IL561020Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER