MEDICARE: MARY GILLIAM 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	RN029921	GA

General Provider Information

NPI Number	:	1720198237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY GILLIAM CRNA

Provider Business Mailing Address
First Line	:	3338 ROSE ARBOR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30340-4065
Country	:	US
Telephone Number	:	770-723-0330
Fax Number	:

Provider Business Practice Location Address
First Line	:	3338 ROSE ARBOR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30340-4065
Country	:	US
Telephone Number	:	770-723-0330
Fax Number	:

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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