Basic Information
| Provider Information | |||||||||
| NPI: | 1518996438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYKE | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | MITCHELL | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12938 | ||||||||
| Address2: | C/O CLINIC MANAGEMENT | ||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30703 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1035 RED BUD RD NE | ||||||||
| Address2: | |||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307016008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068794776 | ||||||||
| FaxNumber: | 7068795841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 12/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN096589 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000550877J | 05 | GA | MEDICAID | 000550877K | 05 | GA | MEDICAID |