Organization
GLEN ELYN ANESTHESIA ASSOCIATES, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. STEPHEN WILSON CRNA (PRESIDENT)
(410) 557-6724
Entity
Organization
Contact information
Practice address
10751 FALLS RD, SUITE 425, LUTHERVILLE, MD 21093-4517
(410) 583-2760
(410) 583-2759
Mailing address
3101 MORNINGSIDE CT, BALDWIN, MD 21013-9528
(410) 557-6724
(410) 557-4355
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
R063574
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
KCE3GL
BLUE CROSS BLUE SHIELD
MD
01
—
P00012294
MEDICARE RAILROAD
MD
01
—
S4320001
FEDERAL CAREFIRST
MD
Enumeration date
06/01/2007
Last updated
09/26/2007
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