Healthcare Provider Details

I. General information

NPI: 1114018165
Provider Name (Legal Business Name): HARRY RODOVICH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SAM PERRY BLVD
FREDERICKSBURG VA
22401-4453
US

IV. Provider business mailing address

804 SCOTT NIXON MEMORIAL DR
AUGUSTA GA
30907-2464
US

V. Phone/Fax

Practice location:
  • Phone: 800-394-4445
  • Fax: 706-955-0720
Mailing address:
  • Phone: 800-394-4445
  • Fax: 706-955-0720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024164731
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: