Provider Demographics
NPI:1740479989
Name:SHIELDS, BART R (CRNA)
Entity type:Individual
Prefix:
First Name:BART
Middle Name:R
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1278
Mailing Address - Street 2:
Mailing Address - City:BEDFORD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60499-1278
Mailing Address - Country:US
Mailing Address - Phone:217-337-2000
Mailing Address - Fax:
Practice Address - Street 1:1400 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2334
Practice Address - Country:US
Practice Address - Phone:217-337-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009210367H00000X
IL209003210367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ206661Medicare PIN