Basic Information
| Provider Information | |||||||||
| NPI: | 1265734271 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHPORT - CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 661495 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352661495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059795882 | ||||||||
| FaxNumber: | 2059791248 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | NORTHPORT | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354763360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053334500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2010 | ||||||||
| LastUpdateDate: | 08/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR BUSINESS SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2053438500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 124766 | 05 | AL | MEDICAID | DR7373 | 01 | AL | RR MCR | OTHER |