Healthcare Provider Details

I. General information

NPI: 1205120003
Provider Name (Legal Business Name): THOMAS M CACCIAPALLE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 PEELER ST
KALAMAZOO MI
49008-2300
US

IV. Provider business mailing address

900 PEELER ST
KALAMAZOO MI
49008-2300
US

V. Phone/Fax

Practice location:
  • Phone: 269-345-8618
  • Fax: 269-345-1508
Mailing address:
  • Phone: 269-345-8618
  • Fax: 269-345-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704245291
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: