Healthcare Provider Details

I. General information

NPI: 1831243062
Provider Name (Legal Business Name): BRIAN MICHAEL GLENN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 W. GRAND AVENUE
DAYTON OH
45405
US

IV. Provider business mailing address

3855 OAKVIEW DRIVE
BEAVERCREEK OH
45430
US

V. Phone/Fax

Practice location:
  • Phone: 865-291-3612
  • Fax:
Mailing address:
  • Phone: 210-485-8049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number748460
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041-293660
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101027
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number09905
License Number StateOH
# 5
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.09905
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: