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NPI Code Detail

MEDICARE: JUSTIN DAVID SMALLRIDGE CRNA

MEDICARE: JUSTIN DAVID SMALLRIDGE 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
1367500000XCertified Registered Nurse AnesthetistAPRN58541WV

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
4P00974070OTHERWVMEDICARE RAILROAD
59333201OTHERWVMEDICARE GROUP

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
21417904848OTHERWVMT STATE BLUE CROSS & BLUE SHIELD
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1417904848
Entity Type Code : Individual
Provider Name (Legal Business Name) : JUSTIN DAVID SMALLRIDGE CRNA
Provider Business Mailing Address
First Line : 230 HOSPITAL PLZ
Second Line :
City : WESTON
State : WV
Zip : 26452-8558
Country : US
Telephone Number : 304-269-8000
Fax Number : 304-269-8090
Provider Business Practice Location Address
First Line : 230 HOSPITAL PLZ
Second Line :
City : WESTON
State : WV
Zip : 26452-8558
Country : US
Telephone Number : 304-269-8000
Fax Number : 304-269-8090
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/30/2006
Last Update Date : 03/11/2025

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Directions to “ JUSTIN DAVID SMALLRIDGE CRNA” Practice Location

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