MEDICARE: GARY PHELPS 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	R130008	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689676462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY PHELPS CRNA

Provider Business Mailing Address
First Line	:	10508 CHESHAM WAY
Second Line	:
City	:	WOODSTOCK
State	:	MD
Zip	:	21163-1364
Country	:	US
Telephone Number	:	410-465-2449
Fax Number	:	410-465-2573

Provider Business Practice Location Address
First Line	:	2411 W BELVEDERE AVE
Second Line	:	MID ATLANTIC NEURO ASSOCIATES
City	:	BALTIMORE
State	:	MD
Zip	:	21215-5228
Country	:	US
Telephone Number	:	410-601-8314
Fax Number	:

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	11/26/2007

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