Healthcare Provider Details

I. General information

NPI: 1972885515
Provider Name (Legal Business Name): MATTHEW JAMES JOHN BAYLEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GENESYS PKWY
GRAND BLANC MI
48439-8065
US

IV. Provider business mailing address

3348 TOWNE PARK DR UNIT 69
LAKE ORION MI
48359-1374
US

V. Phone/Fax

Practice location:
  • Phone: 810-606-6499
  • Fax: 810-606-7245
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704256367
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: