Healthcare Provider Details

I. General information

NPI: 1790275766
Provider Name (Legal Business Name): SPENCER GREENWOOD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 06/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 N 7TH ST
TERRE HAUTE IN
47804
US

IV. Provider business mailing address

5501 IDLE CREEK LN
TERRE HAUTE IN
47802-8185
US

V. Phone/Fax

Practice location:
  • Phone: 812-238-7000
  • Fax:
Mailing address:
  • Phone: 801-786-9775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number118091
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: