Healthcare Provider Details

I. General information

NPI: 1720091390
Provider Name (Legal Business Name): THOMAS G TYNER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 ST MATTHEWS RD
ORANGEBURG SC
29118-1442
US

IV. Provider business mailing address

PO BOX 1245
ORANGEBURG SC
29116-1245
US

V. Phone/Fax

Practice location:
  • Phone: 803-395-2200
  • Fax:
Mailing address:
  • Phone: 803-395-4499
  • Fax: 803-395-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3012
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: