MEDICARE: PHILLIP D UNTHANK 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	4704167210	MI

General Provider Information

NPI Number	:	1073562161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP D UNTHANK CRNA

Provider Business Mailing Address
First Line	:	19146 OUTER DR
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48128-1863
Country	:	US
Telephone Number	:	313-278-4026
Fax Number	:

Provider Business Practice Location Address
First Line	:	22401 FOSTER WINTER DR
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48075-3724
Country	:	US
Telephone Number	:	248-423-5100
Fax Number	:

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

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	12/28/2011

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