Healthcare Provider Details

I. General information

NPI: 1518996438
Provider Name (Legal Business Name): MARC MITCHELL DYKE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 RED BUD RD NE
CALHOUN GA
30701-6008
US

IV. Provider business mailing address

PO BOX 12938 C/O CLINIC MANAGEMENT
CALHOUN GA
30703
US

V. Phone/Fax

Practice location:
  • Phone: 706-879-4776
  • Fax: 706-879-5841
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN096589
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: