Healthcare Provider Details

I. General information

NPI: 1295766590
Provider Name (Legal Business Name): JACK DOWNS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 10/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36475 5 MILE RD
LIVONIA MI
48154-1971
US

IV. Provider business mailing address

2006 HOGBACK RD STE 5A
ANN ARBOR MI
48105-9750
US

V. Phone/Fax

Practice location:
  • Phone: 734-655-2022
  • Fax:
Mailing address:
  • Phone: 734-263-2400
  • Fax: 734-773-3471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704123456
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: