Basic Information
| Provider Information | |||||||||
| NPI: | 1235369885 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CMM ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 64 STARR DR | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342413891 | ||||||||
| FaxNumber: | 7342410014 | ||||||||
| Practice Location | |||||||||
| Address1: | 5623 E DUNBAR RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481619127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342413891 | ||||||||
| FaxNumber: | 7342410014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2009 | ||||||||
| LastUpdateDate: | 10/01/2009 | ||||||||
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| AuthorizedOfficialLastName: | YOUST | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7342413891 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 4704232638 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | MI | PENDING | OTHER |