MEDICARE: MARK ETHERIDGE 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	1-080454	AL

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	:	1659367035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK ETHERIDGE CRNA

Provider Business Mailing Address
First Line	:	5680 SHELBY LN
Second Line	:
City	:	WILMER
State	:	AL
Zip	:	36587-6800
Country	:	US
Telephone Number	:	251-645-2529
Fax Number	:	251-645-2529

Provider Business Practice Location Address
First Line	:	2451 FILLINGIM ST
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36617-2238
Country	:	US
Telephone Number	:	251-471-7035
Fax Number	:	251-471-7042

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

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	05/01/2017

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