MEDICARE: RUSSELL T BEAVERS 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	C00338	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	59622	OTHER	AR	BCBS
2	430014101	OTHER		RRMCR/PGBA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	AR6003788	OTHER		TRICARE/HUMANA

General Provider Information

NPI Number	:	1700881778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL T BEAVERS CRNA

Provider Business Mailing Address
First Line	:	24 GLASGOW CT
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72211-2170
Country	:	US
Telephone Number	:	870-489-1592
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 GLASGOW CT
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72211-2170
Country	:	US
Telephone Number	:	870-489-1592
Fax Number	:

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	04/29/2016

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