Healthcare Provider Details

I. General information

NPI: 1861865941
Provider Name (Legal Business Name): CHARLES GOUIN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2283 SHEVLIN ST
FERNDALE MI
48220-1176
US

IV. Provider business mailing address

2283 SHEVLIN ST
FERNDALE MI
48220-1176
US

V. Phone/Fax

Practice location:
  • Phone: 248-250-9293
  • Fax:
Mailing address:
  • Phone: 248-250-9293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704250956
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: