Healthcare Provider Details

I. General information

NPI: 1164447454
Provider Name (Legal Business Name): TIMOTHY F GALE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 STATE ST
BANGOR ME
04401-6616
US

IV. Provider business mailing address

141 N MAIN ST STE 205
BREWER ME
04412-2055
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-4519
  • Fax: 207-992-4132
Mailing address:
  • Phone: 207-992-4032
  • Fax: 207-992-4034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR022863
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: