Provider Demographics
NPI:1902881733
Name:CORBETT, RICK (CRNA)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:
Last Name:CORBETT
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 1:500 ANDRA DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5796
Mailing Address - Country:US
Mailing Address - Phone:618-343-0048
Mailing Address - Fax:618-343-0048
Practice Address - Street 1:2100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4701
Practice Address - Country:US
Practice Address - Phone:618-343-0048
Practice Address - Fax:618-343-0048
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002579367500000X
IN28184077A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000946369OtherANTHEM PROVIDER NUMBER
IN200938570Medicaid
ILK08018Medicare UPIN
INP01554222Medicare PIN
IN000000946369OtherANTHEM PROVIDER NUMBER