MEDICARE: VERALYNN HEALTH MANAGEMENT, LLC

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	RN065069	GA

General Provider Information

NPI Number	:	1316191075
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VERALYNN HEALTH MANAGEMENT, LLC

Provider Business Mailing Address
First Line	:	273 STOVALL RD
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30241-9094
Country	:	US
Telephone Number	:	706-845-1473
Fax Number	:	336-553-3994

Provider Business Practice Location Address
First Line	:	521 FRANKLIN SPRINGS ST
Second Line	:	DEPT OF ANESTHESIA
City	:	ROYSTON
State	:	GA
Zip	:	30662-3934
Country	:	US
Telephone Number	:	706-245-5071
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CHARLES DERRICK WILSON
Credential	:	CRNA
Telephone Number	:	706-845-1473

Provider Enumeration Date	:	11/07/2008
Last Update Date	:	12/17/2008

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