MEDICARE: PLASTIC CRNA, LLC

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DG7434	OTHER	MS	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1679645352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLASTIC CRNA, LLC

Provider Business Mailing Address
First Line	:	5002 HIGHWAY 39 N BLDG D
Second Line	:
City	:	MERIDIAN
State	:	MS
Zip	:	39301-1078
Country	:	US
Telephone Number	:	601-484-2459
Fax Number	:	601-485-1698

Provider Business Practice Location Address
First Line	:	5002 HIGHWAY 39 N BLDG D
Second Line	:
City	:	MERIDIAN
State	:	MS
Zip	:	39301-1078
Country	:	US
Telephone Number	:	601-484-2459
Fax Number	:	601-485-1698

Authorized Official
Title or Position	:	MANAGER
Name	:	CAROLYN H CRAWFORD
Credential	:
Telephone Number	:	601-484-2459

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	01/25/2011

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Directions to “PLASTIC CRNA, LLC ” Practice Location

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