Healthcare Provider Details

I. General information

NPI: 1689676462
Provider Name (Legal Business Name): GARY PHELPS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 W BELVEDERE AVE MID ATLANTIC NEURO ASSOCIATES
BALTIMORE MD
21215-5228
US

IV. Provider business mailing address

10508 CHESHAM WAY
WOODSTOCK MD
21163-1364
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-8314
  • Fax:
Mailing address:
  • Phone: 410-465-2449
  • Fax: 410-465-2573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR130008
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: