Healthcare Provider Details

I. General information

NPI: 1659367035
Provider Name (Legal Business Name): MARK ETHERIDGE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 FILLINGIM ST
MOBILE AL
36617-2238
US

IV. Provider business mailing address

5680 SHELBY LN
WILMER AL
36587-6800
US

V. Phone/Fax

Practice location:
  • Phone: 251-471-7035
  • Fax: 251-471-7042
Mailing address:
  • Phone: 251-645-2529
  • Fax: 251-645-2529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-080454
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: