Healthcare Provider Details

I. General information

NPI: 1528152543
Provider Name (Legal Business Name): DAVID LEE BEALL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31208
US

IV. Provider business mailing address

137 CROSS CREEK CIRCLE
MACON GA
31210
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-2129
  • Fax:
Mailing address:
  • Phone: 478-405-2646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN159111
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: