Healthcare Provider Details

I. General information

NPI: 1023349420
Provider Name (Legal Business Name): ELIZABETH ANN GEBECK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 800-653-6568
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704246346
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: