Healthcare Provider Details

I. General information

NPI: 1609813773
Provider Name (Legal Business Name): MARC BORCHARDT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 REDMOND RD NW ANESTHESIOLOGY DEPARTMENT
ROME GA
30165-1415
US

IV. Provider business mailing address

7 W BROOK DR SW
ROME GA
30165-3671
US

V. Phone/Fax

Practice location:
  • Phone: 706-291-0291
  • Fax:
Mailing address:
  • Phone: 706-291-9570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN131448
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: