Healthcare Provider Details

I. General information

NPI: 1235468604
Provider Name (Legal Business Name): BRYAN P BRAY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 OXMOOR RD SUITE 111
BIRMINGHAM AL
35209-3502
US

IV. Provider business mailing address

255 W MICHIGAN AVE
JACKSON MI
49201-2218
US

V. Phone/Fax

Practice location:
  • Phone: 800-242-1131
  • Fax: 517-787-7365
Mailing address:
  • Phone: 800-516-5315
  • Fax: 517-787-7365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-096700
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: