Healthcare Provider Details

I. General information

NPI: 1497785323
Provider Name (Legal Business Name): DAVID ANTHONY MILES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 BROADWAY # C-124
MERRILLVILLE IN
46410-7035
US

IV. Provider business mailing address

255 W MICHIGAN AVE
JACKSON MI
49201-2218
US

V. Phone/Fax

Practice location:
  • Phone: 219-738-4929
  • Fax:
Mailing address:
  • Phone: 571-787-6440
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28116051A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209001167
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: