Provider Demographics
NPI:1548473853
Name:MCANULTY, BRIAN TIMOTHY (CRNA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:TIMOTHY
Last Name:MCANULTY
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 1:1517 CHESTERFIELD CT
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-8531
Mailing Address - Country:US
Mailing Address - Phone:618-233-2511
Mailing Address - Fax:
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5360
Practice Address - Country:US
Practice Address - Phone:618-233-7750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered