Provider Demographics
NPI:1831391036
Name:GLEN ELYN ANESTHESIA ASSOCIATES, LLC
Entity type:Organization
Organization Name:GLEN ELYN ANESTHESIA ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:410-557-6724
Mailing Address - Street 1:3101 MORNINGSIDE CT
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MD
Mailing Address - Zip Code:21013-9528
Mailing Address - Country:US
Mailing Address - Phone:410-557-6724
Mailing Address - Fax:410-557-4355
Practice Address - Street 1:10751 FALLS RD
Practice Address - Street 2:SUITE 425
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4517
Practice Address - Country:US
Practice Address - Phone:410-583-2760
Practice Address - Fax:410-583-2759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR063574367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS4320001OtherFEDERAL CAREFIRST
MDKCE3GLOtherBLUE CROSS BLUE SHIELD
MDP00012294OtherMEDICARE RAILROAD
MDKCE3GLOtherBLUE CROSS BLUE SHIELD