Provider Demographics
NPI:1720467392
Name:PREMIERE ANESTHESIA GROUP LLC
Entity type:Organization
Organization Name:PREMIERE ANESTHESIA GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BERTRAND
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHAUFF
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:847-208-0353
Mailing Address - Street 1:5127 HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-5045
Mailing Address - Country:US
Mailing Address - Phone:843-651-2624
Mailing Address - Fax:843-491-4023
Practice Address - Street 1:605 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4506
Practice Address - Country:US
Practice Address - Phone:847-208-0353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010019367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty