1164495735 NPI number — ELIZABETH A GOMON CRNA

Table of content: ELIZABETH A GOMON CRNA (NPI 1164495735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164495735 NPI number — ELIZABETH A GOMON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOMON
Provider First Name:
ELIZABETH
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164495735
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4470 PERRY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND BLANC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48439-1624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-603-2131
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 S BALLENGER HWY
Provider Second Line Business Practice Location Address:
ATTN SURGICAL SERVICES
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48532-3638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-342-4917
Provider Business Practice Location Address Fax Number:
810-342-1335
Provider Enumeration Date:
02/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  4704144384 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3227653 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: EG144384 . This is a "BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".