Healthcare Provider Details

I. General information

NPI: 1770566630
Provider Name (Legal Business Name): MICHAEL TODD RALLS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 05/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S WHITE ST DIRECTOR OF ANESTHESIA
MT PLEASANT IA
52641-2263
US

IV. Provider business mailing address

407 S WHITE ST DIRECTOR OF ANESTHESIA
MT PLEASANT IA
52641-2263
US

V. Phone/Fax

Practice location:
  • Phone: 319-385-6167
  • Fax: 319-385-6754
Mailing address:
  • Phone: 319-385-6167
  • Fax: 319-385-6754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD133382
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: