Healthcare Provider Details

I. General information

NPI: 1629019336
Provider Name (Legal Business Name): KEVIN GARVEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ALLEN MEMORIAL DR
BREMEN GA
30110-2012
US

IV. Provider business mailing address

PO BOX 277368
ATLANTA GA
30384-7368
US

V. Phone/Fax

Practice location:
  • Phone: 770-824-2275
  • Fax: 770-824-2275
Mailing address:
  • Phone: 205-979-5882
  • Fax: 205-979-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-049632
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: