Healthcare Provider Details

I. General information

NPI: 1497792659
Provider Name (Legal Business Name): CHARLES VINCENT WOODSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 MCINTIRE DRIVE, SUITE 150 ATTN: MARIA MITCHELL
BLOOMINGTON IN
47403
US

IV. Provider business mailing address

PO BOX 5635 ATTN: MARIA MITCHELL
BLOOMINGTON IN
47407
US

V. Phone/Fax

Practice location:
  • Phone: 812-337-5003
  • Fax: 812-337-5010
Mailing address:
  • Phone: 812-337-5003
  • Fax: 812-337-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28126400A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: