Provider Demographics
NPI:1528056504
Name:DAMERY, MARY M (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:DAMERY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-383-3303
Practice Address - Fax:217-383-3265
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005925367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-005925OtherIL APN LICENSE #
IL041298740OtherIL LICENSE #
ILL031806OtherCHAMPUS/TRICARE
IL0841504038OtherBCBS OF ILLINOIS
IL0841504038OtherBCBS OF ILLINOIS
ILDE1450Medicare ID - Type UnspecifiedMEDICARE RR GROUP NUMBER
IL794510Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILK21972Medicare PIN