Healthcare Provider Details

I. General information

NPI: 1902168099
Provider Name (Legal Business Name): PHILLIP M. MERRITT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6605 ABERCORN ST STE 108
SAVANNAH GA
31405-5896
US

IV. Provider business mailing address

255 W MICHIGAN AVE PO BOX 1123
JACKSON MI
49201-2218
US

V. Phone/Fax

Practice location:
  • Phone: 912-355-7214
  • Fax:
Mailing address:
  • Phone: 800-516-5315
  • Fax: 517-787-7365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN191722
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: