Organization
ILLINOIS ANESTHESIA COVERAGE P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEROME WILLIAM WELLINGHOFF CRNA (PRESIDENT)
(217) 352-8947
Entity
Organization
Contact information
Practice address
4010 RIVERKNOLL DR, CHAMPAIGN, IL 61822-9213
(217) 352-8947
(217) 352-8947
Mailing address
PO BOX 7048, CHAMPAIGN, IL 61826-7048
(217) 352-8947
(217) 352-8947
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
209 001163
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
092-253-24
BLUE CROSS BLUE SHIELD IL
IL
01
—
A001
TRICARE MILITARY
—
01
—
CG3273
MEDICARE, RAILROAD
IL
Enumeration date
03/05/2007
Last updated
03/31/2009
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