Individual
MR. WALTER LAESCH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
C.R.N.A.
Contact information
Practice address
40 10 RIVERKNOLL DR, CHAMPAIGN, IL 61822
(217) 356-5963
(217) 352-8947
Mailing address
1016 W UNION ST, CHAMPAIGN, IL 61821-3322
(217) 359-2752
(217) 359-8923
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
209-000371
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
09223524
BC/BS GROUP ID NO.
IL
01
—
216564000
WORKMAN'S COMP GROUP ID
IL
01
—
371390028001
TRICARE GROUP ID NO.
IL
01
—
430052840
RR MEDICARE GROUP ID NO.
IL
01
—
CG3273
RR MEDICARE GROUP ID NO.
IL
Enumeration date
11/21/2005
Last updated
10/05/2011
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