Healthcare Provider Details

I. General information

NPI: 1134137052
Provider Name (Legal Business Name): ADAM REIDENBACH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 W MARKET STREET
LIMA OH
45801
US

IV. Provider business mailing address

PO BOX 71-0776
COLUMBUS OH
43271-0776
US

V. Phone/Fax

Practice location:
  • Phone: 419-227-3361
  • Fax:
Mailing address:
  • Phone: 419-228-1506
  • Fax: 419-228-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN282678
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: