Healthcare Provider Details

I. General information

NPI: 1821046145
Provider Name (Legal Business Name): GERALD TODD ADCOCK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 MARION AVE
MCCOMB MS
39648-2705
US

IV. Provider business mailing address

215 MARION AVE
MCCOMB MS
39648-2705
US

V. Phone/Fax

Practice location:
  • Phone: 601-249-5500
  • Fax: 601-249-1709
Mailing address:
  • Phone: 601-249-5500
  • Fax: 601-249-1709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR853069
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: