Healthcare Provider Details

I. General information

NPI: 1518909084
Provider Name (Legal Business Name): JEREMY BROCKFORD DUREL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 WATERS AVE
SAVANNAH GA
31404-6220
US

IV. Provider business mailing address

PO BOX 116324
ATLANTA GA
30368-2032
US

V. Phone/Fax

Practice location:
  • Phone: 912-354-3510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR130642
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: