MEDICARE: MR. JEFFREY EARL PAGE 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	163W00000X	Registered Nurse	RN136203	GA
2	367500000X	Certified Registered Nurse Anesthetist	RN136203	GA

General Provider Information

NPI Number	:	1407828452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY EARL PAGE CRNA

Provider Business Mailing Address
First Line	:	55 CLOISTER CV
Second Line	:
City	:	NEWNAN
State	:	GA
Zip	:	30265-4116
Country	:	US
Telephone Number	:	678-570-5885
Fax Number	:

Provider Business Practice Location Address
First Line	:	7950 MARTIN LOOP
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31905-5647
Country	:	US
Telephone Number	:	706-544-4375
Fax Number	:

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

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	05/19/2009

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