Healthcare Provider Details

I. General information

NPI: 1992758064
Provider Name (Legal Business Name): STEPHEN J BENEDICT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4665 DOUGLAS CIR NW SUITE 101
CANTON OH
44718-3673
US

IV. Provider business mailing address

255 W MICHIGAN AVE
JACKSON MI
49201-2218
US

V. Phone/Fax

Practice location:
  • Phone: 330-489-1698
  • Fax: 330-489-1325
Mailing address:
  • Phone: 517-787-6440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN141639
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: