Healthcare Provider Details

I. General information

NPI: 1912097114
Provider Name (Legal Business Name): MICHAEL G CIPOLAT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 SOUTHVIEW DR
BLUEFIELD WV
24701-4317
US

IV. Provider business mailing address

1333 SOUTHVIEW DR
BLUEFIELD WV
24701-4317
US

V. Phone/Fax

Practice location:
  • Phone: 304-327-2900
  • Fax: 304-327-2989
Mailing address:
  • Phone: 304-327-2900
  • Fax: 304-327-2989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number25556
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: