Provider Demographics
NPI:1992795892
Name:ANESTHESIA ASSOC OF NORTHEAST ILLINOIS
Entity type:Organization
Organization Name:ANESTHESIA ASSOC OF NORTHEAST ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KNIFFEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-915-7318
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-0100
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:6701 159TH ST
Practice Address - Street 2:INGALLS SAME DAY SURGERY
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1758
Practice Address - Country:US
Practice Address - Phone:708-915-7318
Practice Address - Fax:708-429-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0161887464OtherBCBSIL GROUP NUMBER
0161887464OtherBCBSIL GROUP NUMBER
IL958870Medicare PIN