Healthcare Provider Details

I. General information

NPI: 1316124985
Provider Name (Legal Business Name): RUSSELL WADE DAILY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2008
Last Update Date: 01/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S MONTGOMERY AVE
SHEFFIELD AL
35660-6334
US

IV. Provider business mailing address

341 KINGSTON DR
FLORENCE AL
35633-1728
US

V. Phone/Fax

Practice location:
  • Phone: 256-386-4005
  • Fax:
Mailing address:
  • Phone: 256-765-2271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-097495
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: