Healthcare Provider Details

I. General information

NPI: 1316352826
Provider Name (Legal Business Name): KENNETH CROSSWHITE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 MEDICAL CENTER PKWY
SELMA AL
36701-6748
US

IV. Provider business mailing address

296 SHADOW CREEK LOOP
CAMDEN AL
36726-1846
US

V. Phone/Fax

Practice location:
  • Phone: 334-418-4100
  • Fax:
Mailing address:
  • Phone: 334-455-9905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-095951
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: