Basic Information
| Provider Information | |||||||||
| NPI: | 1093993990 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARY W PHELPS CRNA INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10508 CHESHAM WAY | ||||||||
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| City: | WOODSTOCK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211630000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013170020 | ||||||||
| FaxNumber: | 3013170028 | ||||||||
| Practice Location | |||||||||
| Address1: | 1838 GREENTREE ROAD | ||||||||
| Address2: | #180 | ||||||||
| City: | BALTO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013170020 | ||||||||
| FaxNumber: | 3013170028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 02/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | PHELPS | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3013170020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R130008 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | F942001 | 01 | DC | CAREFIRST DC | OTHER | NA95GW | 01 | MD | CAREFIRST MD | OTHER |