Healthcare Provider Details

I. General information

NPI: 1720043219
Provider Name (Legal Business Name): GROVER SCOTT CRUISE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S 12TH AVE
HATTIESBURG MS
39401-6106
US

IV. Provider business mailing address

PO BOX 2295
ASHEVILLE NC
28802-2295
US

V. Phone/Fax

Practice location:
  • Phone: 601-310-4509
  • Fax:
Mailing address:
  • Phone: 828-398-5244
  • Fax: 828-360-3080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR847413
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: