Provider Demographics
NPI:1528260635
Name:LAKE ANESTHESIA ASSOCIATES
Entity type:Organization
Organization Name:LAKE ANESTHESIA ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:AFRICANO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:708-798-5838
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-0158
Mailing Address - Country:US
Mailing Address - Phone:708-798-5838
Mailing Address - Fax:
Practice Address - Street 1:19624 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2077
Practice Address - Country:US
Practice Address - Phone:708-798-5838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0008253495OtherAETNA PIN
ILDG3846OtherPALMETTO GBA/ RR MEDICARE
ILDG3846OtherPALMETTO GBA/ RR MEDICARE