Healthcare Provider Details

I. General information

NPI: 1699141762
Provider Name (Legal Business Name): CAROL BETH MCCREARY R N
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2766 W 11 MILE RD SUITE 2
BERKLEY MI
48072-3033
US

IV. Provider business mailing address

17010 J DR N
MARSHALL MI
49068-9440
US

V. Phone/Fax

Practice location:
  • Phone: 248-542-2424
  • Fax:
Mailing address:
  • Phone: 269-781-0676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704152436
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: