Healthcare Provider Details

I. General information

NPI: 1811993769
Provider Name (Legal Business Name): MICHAEL C LOOMIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7918 MAIN STREET SUITE 204
FOGELSVILLE PA
18051-0488
US

IV. Provider business mailing address

7918 MAIN ST SUITE 204
FOGELSVILLE PA
18051-1744
US

V. Phone/Fax

Practice location:
  • Phone: 610-366-9536
  • Fax: 610-366-9538
Mailing address:
  • Phone: 610-366-9536
  • Fax: 610-366-9538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN254017L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-254017-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: