Healthcare Provider Details

I. General information

NPI: 1700833100
Provider Name (Legal Business Name): WILLIAM GILBERT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 02/27/2024
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30671 STEPHENSON HWY
MADISON HEIGHTS MI
48071-1635
US

IV. Provider business mailing address

DEPT 203401 PO BOX 67000
DETROIT MI
48267-0001
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-9770
  • Fax:
Mailing address:
  • Phone: 952-442-9770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD175496
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704198561
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: