MEDICARE: MR. MICHAEL ALLEN NORTHWAY 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	163W00000X	Registered Nurse	R082308	GA
2	367500000X	Certified Registered Nurse Anesthetist	AA083105	ME

General Provider Information

NPI Number	:	1770584708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL ALLEN NORTHWAY CRNA

Provider Business Mailing Address
First Line	:	20 HARTFORD ST
Second Line	:
City	:	HOULTON
State	:	ME
Zip	:	04730-1891
Country	:	US
Telephone Number	:	207-532-2900
Fax Number	:	207-532-5974

Provider Business Practice Location Address
First Line	:	20 HARTFORD ST
Second Line	:
City	:	HOULTON
State	:	ME
Zip	:	04730-1891
Country	:	US
Telephone Number	:	207-532-2900
Fax Number	:	207-532-5974

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

Provider Enumeration Date	:	08/01/2005
Last Update Date	:	02/28/2014

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