MEDICARE: ROBERT L ELLISON 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	207L00000X	Anesthesiology Physician	N13917	ID
2	367500000X	Certified Registered Nurse Anesthetist	RNA-209	ID
3	367500000X	Certified Registered Nurse Anesthetist	AP30004667	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	P00137189	OTHER		RAILROAD MEDICARE

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
2	A3565	OTHER	ID	BC ID
3	N13917	OTHER	ID	IDAHO LICENSE
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265425714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT L ELLISON CRNA

Provider Business Mailing Address
First Line	:	PO BOX 1829
Second Line	:
City	:	COEUR D ALENE
State	:	ID
Zip	:	83816-1829
Country	:	US
Telephone Number	:	208-667-9334
Fax Number	:	208-664-2341

Provider Business Practice Location Address
First Line	:	2300 W A ST
Second Line	:
City	:	MOSCOW
State	:	ID
Zip	:	83843-4038
Country	:	US
Telephone Number	:	208-883-1500
Fax Number	:	208-882-7701

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

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	07/13/2010

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Directions to “ ROBERT L ELLISON CRNA” Practice Location

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