Healthcare Provider Details

I. General information

NPI: 1851575260
Provider Name (Legal Business Name): MELVIN L SELF JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 RIVER RD
GREENWOOD MS
38930-4030
US

IV. Provider business mailing address

PO BOX 1410
GREENWOOD MS
38935-1410
US

V. Phone/Fax

Practice location:
  • Phone: 662-459-2613
  • Fax: 662-459-1159
Mailing address:
  • Phone: 662-459-2613
  • Fax: 662-459-1159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR855594
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number247073
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: