Healthcare Provider Details

I. General information

NPI: 1598717076
Provider Name (Legal Business Name): JEFFREY MICHAEL AVERY C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST NORTH MS MEDICAL CENTER
TUPELO MS
38801-4934
US

IV. Provider business mailing address

810 ROSE LN
AMORY MS
38821-2109
US

V. Phone/Fax

Practice location:
  • Phone: 662-841-3000
  • Fax:
Mailing address:
  • Phone: 662-315-6092
  • Fax: 662-651-4636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR855712
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: