MEDICARE: KENNETH R ALTIER 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	RN126301	OH

General Provider Information

NPI Number	:	1588690473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH R ALTIER CRNA

Provider Business Mailing Address
First Line	:	255 W MICHIGAN AVE
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49201-2218
Country	:	US
Telephone Number	:	517-787-6440
Fax Number	:	517-787-4146

Provider Business Practice Location Address
First Line	:	3915 E. GAGEVILLE RD
Second Line	:
City	:	KINGSVILLE
State	:	OH
Zip	:	44048
Country	:	US
Telephone Number	:	440-224-2950
Fax Number	:

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

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	09/25/2009

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