1205346483 NPI number — BRITLEY ANN WHITE CRNA

Table of content: BRITLEY ANN WHITE CRNA (NPI 1205346483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205346483 NPI number — BRITLEY ANN WHITE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE
Provider First Name:
BRITLEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205346483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3988
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62902-3988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-549-0721
Provider Business Mailing Address Fax Number:
618-529-0449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 W JACKSON ST
Provider Second Line Business Practice Location Address:
SIH MEDICAL GROUP ANESTHESIOLOGY
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-549-0721
Provider Business Practice Location Address Fax Number:
618-529-0529
Provider Enumeration Date:
10/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  209016742 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 114636 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 214881 . This is a "MULTISPECIALTY GROUP PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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