Basic Information
| Provider Information | |||||||||
| NPI: | 1619989175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIRLEY | ||||||||
| FirstName: | BEN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8973 HIGHWAY 495 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393059288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017374910 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2124 14TH ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015536000 | ||||||||
| FaxNumber: | 6015536115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R858466 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 05088759 | 05 | MS | MEDICAID | 730-14502 | 01 | AL | BLUE CROSS OF AL | OTHER | 009949395 | 05 | AL | MEDICAID |