Healthcare Provider Details

I. General information

NPI: 1508950064
Provider Name (Legal Business Name): MARK COMBS C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 NORTH EAST AVE ANESTHESIA DEPARTMENT
JACKSON MI
49201
US

IV. Provider business mailing address

1189 BANDERA DRIVE
ANN ARBOR MI
48103
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-4963
  • Fax:
Mailing address:
  • Phone: 734-995-9956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704178623
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: