Healthcare Provider Details

I. General information

NPI: 1023536190
Provider Name (Legal Business Name): PHILIP ROSS LEPINE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 PINE GROVE AVE
PORT HURON MI
48060-3511
US

IV. Provider business mailing address

911 GEORGIA AVE
MARYSVILLE MI
48040-1277
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704270813
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: