Healthcare Provider Details

I. General information

NPI: 1831141795
Provider Name (Legal Business Name): WILLIAM GRANT CARRUTHERS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 CLEARVISTA DR NORTH/FAMILY ROOMS
INDIANAPOLIS IN
46256-1695
US

IV. Provider business mailing address

PO BOX 19751
INDIANAPOLIS IN
46219-0751
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-5890
  • Fax: 317-355-2205
Mailing address:
  • Phone: 317-355-5837
  • Fax: 317-904-3929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041346090
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28182196A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: