Healthcare Provider Details

I. General information

NPI: 1134656390
Provider Name (Legal Business Name): LEVI CHASE TAYLOR CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2017
Last Update Date: 05/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL CENTER DR
SPRINGFIELD OH
45504-2687
US

IV. Provider business mailing address

12975 BROADGAUGE RD
SOUTH VIENNA OH
45369-8709
US

V. Phone/Fax

Practice location:
  • Phone: 937-523-1000
  • Fax:
Mailing address:
  • Phone: 937-631-5676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number019494
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: