Unknown Individual – Certified Registered Nurse Anesthetist, NPI 1629170618

Unknown Individual is a healthcare provider. based in Mount vernon, Illinois. specializing in Certified Registered Nurse Anesthetist. They hold a License No. R54232 (ND). The NPI Number for Unknown Individual is 1629170618

Main info

Organization
Inactive
24 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1629170618
Phone
(618) 241-1108
Address
605 N 12TH ST
Deactivation Date
22 January 2026

Doctor Profile

Medical School Name
OTHER
Secondary Phone
3085348800
Graduation Year
2002 (24 years ago)
PAC ID
8123924602
Group Practice PAC ID
6709969751
Professional Enrollment ID
I20170718002285

Contacts

Main Contact
https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service
Data current as of
19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience32
Completeness85
Years active:0State licenses:3Other namesUpdated within 12 months

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Provider Addresses for Unknown Individual

  • 605, North 12th Street, Mount Vernon, Jefferson County, Illinois, 62864, United States

    MOUNT VERNON, IL 628642857

    Phone: (618) 241-1108

    Fax: (618) 241-3805

    Type: Location

  • 202 PROSPECT DR

    GLENDIVE, MT 593301999

    Phone: (406) 345-3306

    Type: Mailing

  • 2305 37th Ave SW

    Minot, ND 587017669

    Phone: (701) 857-5000

    Type: Location

  • 202 Prospect Dr

    Glendive, MT 593301999

    Phone: (406) 345-3306

    Type: Location

  • 4227, Lincolnshire Drive, Mount Vernon, Jefferson County, Illinois, 62864, United States

    MOUNT VERNON, IL 628642157

    Phone: (618) 242-2317

    Fax: (618) 242-9710

    Type: Mailing

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 62864)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.
PAC ID: 6709969751View full group profile
NameSpecialtyState
Certified Registered Nurse Anesthetist (Crna)MN
-NE
Certified Registered Nurse Anesthetist (Crna)NE
Certified Registered Nurse Anesthetist (Crna)NE
Certified Registered Nurse Anesthetist (Crna)NE
Certified Registered Nurse Anesthetist (Crna)KY
A N E S T H E S I O L O G YNE
Certified Registered Nurse Anesthetist (Crna)IA
Certified Registered Nurse Anesthetist (Crna)NE
Certified Registered Nurse Anesthetist (Crna)HI

Reviews

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Frequently asked questions

Does Unknown Individual share an NPI with anyone else?
NPI numbers are unique to each provider or organization — Unknown Individual uses 1629170618.
Is Unknown Individual's NPI deactivated?
The extract indicates Unknown Individual is not in an active NPI state.
What is Unknown Individual best known for clinically?
Directory data describes Unknown Individual with Certified Registered Nurse Anesthetist. Clinical services aligned with this taxonomy classification.
Where should I expect Unknown Individual on a map?
Expect Mount Vernon, Illinois as a primary anchor for Unknown Individual unless the record lists multiple sites.
How many locations tie to this NPI?
5 practice locations appear in the available data.

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