Healthcare Provider Details

I. General information

NPI: 1013990985
Provider Name (Legal Business Name): OLIN BRADFORD HUTTO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1789 OLD 96 INDIAN TRL
BATESBURG SC
29006-9618
US

IV. Provider business mailing address

1789 OLD 96 INDIAN TRL
BATESBURG SC
29006-9618
US

V. Phone/Fax

Practice location:
  • Phone: 803-443-3807
  • Fax:
Mailing address:
  • Phone: 803-443-3807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1166
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: