Basic Information
| Provider Information | |||||||||
| NPI: | 1700848512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHOBERRY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475010032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122542760 | ||||||||
| FaxNumber: | 8122548636 | ||||||||
| Practice Location | |||||||||
| Address1: | 1314 E WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475012120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122542760 | ||||||||
| FaxNumber: | 8122548636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 03/30/2010 | ||||||||
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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 | 28066860A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200195480 | 05 | IN | MEDICAID | 000000190468 | 01 | IN | ANTHEM | OTHER |