MEDICARE: MICHAEL P ENNIS 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	213881	MA
2	367500000X	Certified Registered Nurse Anesthetist	11011995	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346241288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL P ENNIS CRNA

Provider Business Mailing Address
First Line	:	3645 SLAYTON AVE
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34286-4211
Country	:	US
Telephone Number	:	401-486-8969
Fax Number	:

Provider Business Practice Location Address
First Line	:	55 FOGG RD
Second Line	:
City	:	WEYMOUTH
State	:	MA
Zip	:	02190-2432
Country	:	US
Telephone Number	:	781-624-8000
Fax Number	:

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	12/09/2024

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