MEDICARE: MR. BRYAN T AFFOLTER 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	APN11209	TN
2	367500000X	Certified Registered Nurse Anesthetist	RN102072	TN
3	367500000X	Certified Registered Nurse Anesthetist	RN153379	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3141447	OTHER	TN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265407134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRYAN T AFFOLTER CRNA

Provider Business Mailing Address
First Line	:	PO BOX 11114
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37401-2114
Country	:	US
Telephone Number	:	423-899-1600
Fax Number	:	423-892-2171

Provider Business Practice Location Address
First Line	:	924 SPRING CREEK RD
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37412-3910
Country	:	US
Telephone Number	:	423-899-1600
Fax Number	:	423-899-2171

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

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	08/27/2008

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