Basic Information
Provider Information | |||||||||
NPI: | 1144273921 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUCKREIS | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 255 ENTERPRISE BLVD | ||||||||
Address2: | SUITE 250 | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296156300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8644540888 | ||||||||
FaxNumber: | 8644541130 | ||||||||
Practice Location | |||||||||
Address1: | 701 GROVE RD | ||||||||
Address2: | 2ND FLOOR ANESTHESIA DEPT. | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296055611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8644557111 | ||||||||
FaxNumber: | 8644556441 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APRN2393 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | AN0841 | 05 | SC |   | MEDICAID | 20012216 | 01 | SC | INDIVIDUAL SELECT HEALTH | OTHER | 20031911 | 01 | SC | SELECT HEALTH GROUP | OTHER |