Provider Demographics
NPI:1992064166
Name:AIRWAY ANESTHESIA PC
Entity type:Organization
Organization Name:AIRWAY ANESTHESIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHENOWETH
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:309-454-4617
Mailing Address - Street 1:1105 STERLING GLEN CC CT
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5297
Mailing Address - Country:US
Mailing Address - Phone:309-454-4617
Mailing Address - Fax:877-757-6325
Practice Address - Street 1:1105 STERLING GLEN CC CT
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-5297
Practice Address - Country:US
Practice Address - Phone:309-454-4617
Practice Address - Fax:877-757-6325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001108207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL617834300OtherDEPT OF LABOR
ILIL7374Medicare PIN