Healthcare Provider Details

I. General information

NPI: 1528046448
Provider Name (Legal Business Name): CHARLES WILLIAM MERRY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ST VINCENTS MEDICAL CENTER
JACKSONVILLE FL
32223
US

IV. Provider business mailing address

4839 PARKHURST PL
JACKSONVILLE FL
32256-6046
US

V. Phone/Fax

Practice location:
  • Phone: 904-568-6698
  • Fax:
Mailing address:
  • Phone: 904-568-6698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP 2750812
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: