Healthcare Provider Details

I. General information

NPI: 1669624201
Provider Name (Legal Business Name): MARK STEPHEN FYN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2008
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22101 MOROSS RD ANESTHESIA DEPT
DETROIT MI
48236-2148
US

IV. Provider business mailing address

17420 ROSEVILLE BLVD
ROSEVILLE MI
48066-2866
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-7075
  • Fax:
Mailing address:
  • Phone: 586-445-1072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704201153
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: