Healthcare Provider Details

I. General information

NPI: 1831133578
Provider Name (Legal Business Name): ROGER V CRUSE II CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/23/2024
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HOSPITAL DR
SPENCER WV
25276-1050
US

IV. Provider business mailing address

200 HOSPITAL DR
SPENCER WV
25276-1050
US

V. Phone/Fax

Practice location:
  • Phone: 304-927-6372
  • Fax: 304-927-6390
Mailing address:
  • Phone: 304-927-4444
  • Fax: 304-927-6837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.08297
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number116450
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: