MEDICARE: DENNIS C MACIESKI 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	N-18888	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225065196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS C MACIESKI CRNA

Provider Business Mailing Address
First Line	:	PO BOX 3206
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83403-3206
Country	:	US
Telephone Number	:	208-523-4609
Fax Number	:	208-523-2025

Provider Business Practice Location Address
First Line	:	2325 CORONADO ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7407
Country	:	US
Telephone Number	:	208-552-2700
Fax Number	:

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

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	07/12/2007

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