Healthcare Provider Details

I. General information

NPI: 1295848224
Provider Name (Legal Business Name): JEFFERY HODGE REID SR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W 15TH ST
LIBERAL KS
67901-2455
US

IV. Provider business mailing address

PO BOX 120
ALMA CO
80420-0120
US

V. Phone/Fax

Practice location:
  • Phone: 620-629-6259
  • Fax: 620-629-6655
Mailing address:
  • Phone: 719-836-0219
  • Fax: 719-836-0219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1433359042
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: