MEDICARE: ELIZABETH HEATH CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	4704148122	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	EH148122	OTHER	MI	BLUE CROSS OF MI

General Provider Information

NPI Number	:	1043275985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH HEATH CRNA

Provider Business Mailing Address
First Line	:	233 W 1ST ST
Second Line	:
City	:	WACONIA
State	:	MN
Zip	:	55387-1302
Country	:	US
Telephone Number	:	952-442-9770
Fax Number	:	952-442-3630

Provider Business Practice Location Address
First Line	:	28500 ORCHARD LAKE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-2936
Country	:	US
Telephone Number	:	952-442-9770
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	07/08/2007

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