MEDICARE: MRS. MARY ETHEL ROEHM 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	R59124	SC
2	367500000X	Certified Registered Nurse Anesthetist	R59124	SC

General Provider Information

NPI Number	:	1609856657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY ETHEL ROEHM CRNA

Provider Business Mailing Address
First Line	:	8 AUTUMN OAK WAY
Second Line	:
City	:	TRAVELERS REST
State	:	SC
Zip	:	29690-4066
Country	:	US
Telephone Number	:	864-836-6151
Fax Number	:	864-836-6157

Provider Business Practice Location Address
First Line	:	200 PATEWOOD DR
Second Line	:	STE B 100
City	:	GREENVILLE
State	:	SC
Zip	:	29615-3593
Country	:	US
Telephone Number	:	864-451-5200
Fax Number	:

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

Provider Enumeration Date	:	01/18/2006
Last Update Date	:	04/16/2013

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