Healthcare Provider Details

I. General information

NPI: 1104841477
Provider Name (Legal Business Name): OLIVER DAVIDSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 EVA RD NE
CULLMAN AL
35055-6006
US

IV. Provider business mailing address

2613 N BETHEL RD
DECATUR AL
35603-5945
US

V. Phone/Fax

Practice location:
  • Phone: 800-277-8151
  • Fax: 336-841-6217
Mailing address:
  • Phone: 256-351-0775
  • Fax: 256-351-0775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-020760
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: