Healthcare Provider Details

I. General information

NPI: 1013999176
Provider Name (Legal Business Name): MARLIN SEAN RYDER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 BIG COVE RD SE ANESTHESIA DEPT.
HUNTSVILLE AL
35801-3750
US

IV. Provider business mailing address

PO BOX 1389
HUNTSVILLE AL
35807-0389
US

V. Phone/Fax

Practice location:
  • Phone: 256-265-8120
  • Fax: 256-265-8969
Mailing address:
  • Phone: 205-979-5882
  • Fax: 205-979-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR866237
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-082882
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: