MEDICARE: MR. MICHAEL J MCDONALD CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	066841	MO

General Provider Information

NPI Number	:	1073561338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL J MCDONALD CRNA

Provider Business Mailing Address
First Line	:	942 RANCH BLUFF 'RD.
Second Line	:
City	:	VILLA RIDGE
State	:	MO
Zip	:	63089-1010
Country	:	US
Telephone Number	:	636-221-1134
Fax Number	:

Provider Business Practice Location Address
First Line	:	942 RANCH BLUFF RD
Second Line	:
City	:	VILLA RIDGE
State	:	MO
Zip	:	63089-1478
Country	:	US
Telephone Number	:	636-221-1134
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	10/24/2016

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