Healthcare Provider Details

I. General information

NPI: 1124227061
Provider Name (Legal Business Name): BENJAMIN MICHAEL STEPHENS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

220 OLD HIGHWAY 5 N
THOMASVILLE AL
36784-1812
US

IV. Provider business mailing address

220 OLD HIGHWAY 5 N
THOMASVILLE AL
36784-1812
US

V. Phone/Fax

Practice location:
  • Phone: 334-636-1333
  • Fax:
Mailing address:
  • Phone: 334-636-1333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-084033
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: