Healthcare Provider Details

I. General information

NPI: 1538595079
Provider Name (Legal Business Name): BRADLEY ALLEN GREEN CRNA, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 BIDDLE AVE
WYANDOTTE MI
48192-4668
US

IV. Provider business mailing address

9261 FOX AVE
ALLEN PARK MI
48101-1507
US

V. Phone/Fax

Practice location:
  • Phone: 734-246-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704265869
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: