Basic Information
| Provider Information | |||||||||
| NPI: | 1972596856 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SERVICK | ||||||||
| FirstName: | CHESTER | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 567 BRADFORD CT | ||||||||
| Address2: | |||||||||
| City: | ELMORE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434169553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198620044 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2801 BAY PARK DR | ||||||||
| Address2: | DEPARTMENT OF SURGERY | ||||||||
| City: | OREGON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436164920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196907652 | ||||||||
| FaxNumber: | 4196977726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
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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 | RN277026 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 5182111 | 05 | MI | MEDICAID | 000000479840 | 01 | OH | ANTHEM | OTHER | 04097A | 01 | OH | PARAMOUNT | OTHER | 4486239 | 05 | MI | MEDICAID | 341881145-003 | 01 | OH | MMO | OTHER | P00378258 | 01 | OH | RRMC | OTHER | 2333522 | 05 | OH | MEDICAID | 5182111 | 01 | MI | MICHIGAN MEDICAID | OTHER | 000000246991 | 01 | OH | ANTHEM | OTHER |