MEDICARE: MARY WATTS 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	4704105626	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MW105626	OTHER	MI	BLUE CROSS OF MI

General Provider Information

NPI Number	:	1467432732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY WATTS CRNA

Provider Business Mailing Address
First Line	:	PO BOX 67000
Second Line	:	DEPT 203401
City	:	DETROIT
State	:	MI
Zip	:	48267-0002
Country	:	US
Telephone Number	:	952-442-9770
Fax Number	:

Provider Business Practice Location Address
First Line	:	28500 ORCHARD LAKE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-2936
Country	:	US
Telephone Number	:	952-442-9770
Fax Number	:

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

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	08/17/2007

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