Souphaphone Bounmythavong Nicksic, CRNA

Primary specialty

Certified Registered Nurse AnesthetistTaxonomy code 367500000X

License

209008677 Issued in IL

Practice address

1425 N Randall Rd
Elgin, IL 60123-2300

Phone

(224) 783-1065

Fax

(224) 783-2852

NPI assigned

Dec 4, 2008

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 1

• Sou Bounmythavong Other name

Electronic endpoints 2

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

Specialty

Certified Registered Nurse Anesthetist (Crna)

Education

Other, 2009

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Advocate Health and Hospitals CorporationGroup PAC ID 7810800935, 3,081 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Advocate Sherman Hospital Hospital, Elgin, IL, CCN 140030

Medicare enrollment (NPD)

Enrolled

Credentials

Certified Registered Nurse

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Advocate Health and Hospitals Corporation

  • Multi-Specialty Clinic/Center
  • Oak Brook, IL
  • NPI 1700824455
  Medicare reassignment Care Compare group NPD
• Apollo Medical Group of Illinois LLC

  • Anesthesiology Physician
  • Chicago, IL
  • NPI 1730934597

  Nurse Anesthetist, Certified Registered

  Medicare reassignment NPD
• Illinois Gastroenterology Group, LLC

  • Gastroenterology Physician
  • Elgin, IL
  • NPI 1316277817
  Medicare reassignment NPD
• Valley Ambulatory Surgery Center Anesthesiology LTD

  • Anesthesiology Physician
  • St Charles, IL
  • NPI 1629082326
  Medicare reassignment NPD
• Midwest Anesthesia Providers S.C

  • Anesthesiology Physician
  • Saint Louis, MO
  • NPI 1295189082

  IL, Nurse Anesthetist, Certified Registered

  Medicare reassignment NPD
• Advocate Health & Hospitals Corp.

  • Emergency Medicine Physician
  • Chicago, IL
  • NPI 1750315545
  NPD
• Advocate Health and Hospitals Corporation

  • Children's Hospital
  • Oak Lawn, IL
  • NPI 1508315516
  NPD
• Elgin Gastroenterology Endoscopy Center LLC

  • Ambulatory Surgical Clinic/Center
  • Elgin, IL
  • NPI 1992875454
  NPD
• Elgin Gastroenterology SC

  • Gastroenterology Physician
  • Elgin, IL
  • NPI 1932291101
  NPD
• Northwest Gastroenterologists SC

  • Specialist
  • Arlington Heights, IL
  • NPI 1801886221
  NPD
• Valley Ambulatory Surgery Center, LP

  • Ambulatory Surgical Clinic/Center
  • St Charles, IL
  • NPI 1104819424
  NPD
• Windy City Anesthesia PC

  • Certified Registered Nurse Anesthetist
  • Frankfort, IL
  • NPI 1932248622

  Nurse Anesthetist, Certified Registered

  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Advocate Sherman Hospital

  • General Acute Care Hospital
  • Elgin, IL
  • NPI 1629026364
  Care Compare affiliation
• Sherman Hospital

  • Skilled Nursing Facility
  • Elgin, IL
  • NPI 1275584302

  Hospital

  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1228348800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1693353600000",
    "number": "1740425701",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "29373 NETWORK PL",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606731293",
            "telephone_number": "847-390-5900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1425 N RANDALL RD",
            "city": "ELGIN",
            "state": "IL",
            "postal_code": "601232300",
            "telephone_number": "224-783-1065",
            "fax_number": "224-783-2852"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2600 Greenbush St",
            "address_purpose": "LOCATION",
            "city": "Lafayette",
            "state": "IN",
            "postal_code": "479042477",
            "country_code": "US",
            "telephone_number": "765-448-8000",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2475 Dean St",
            "address_purpose": "LOCATION",
            "city": "Saint Charles",
            "state": "IL",
            "postal_code": "601754831",
            "country_code": "US",
            "telephone_number": "630-584-9800",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "NICKSIC",
        "first_name": "SOUPHAPHONE",
        "middle_name": "BOUNMYTHAVONG",
        "credential": "CRNA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2008-12-04",
        "last_updated": "2023-08-30",
        "certification_date": "2023-08-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "IN",
            "license": "28181986A",
            "primary": false
        },
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "IL",
            "license": "209008677",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM PROVIDER NUMBER",
            "identifier": "000000610221",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200949460",
            "state": "IN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "snicksic344509@direct.myadvocateaurora.org",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "1425 N Randall Rd",
            "city": "Elgin",
            "state": "IL",
            "country_code": "US",
            "postal_code": "601232300",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://EpicFHIR.aurora.org/FHIR/MYAURORA/api/FHIR/DSTU2/",
            "affiliation": "N",
            "address_1": "1425 N Randall Rd",
            "city": "Elgin",
            "state": "IL",
            "country_code": "US",
            "postal_code": "601232300",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "first_name": "SOU",
            "last_name": "BOUNMYTHAVONG",
            "credential": "CRNA",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Rubina D Nguyen, D.D.S.
• Esmeralda Nicanor
• Lindsay Nickels
• Dale Charles Nickelsen, D.D.S.
• Jon D Nickelsen, DDS
• Anthony Alvarez Nidea, M.D.
• Eric Nielsen
• Michael Nikolov, M.D.
• Asim Nisar, M.D.
• Nighat Nisar, M.D.

• Certified Registered Nurse Anesthetist in Elgin, IL
• Providers in Elgin, IL by specialty
• Certified Registered Nurse Anesthetist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 30, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.