1154326874 NPI number — MRS. BRENDA RAE RUTHERFORD CRNA

Table of content: MRS. BRENDA RAE RUTHERFORD CRNA (NPI 1154326874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154326874 NPI number — MRS. BRENDA RAE RUTHERFORD CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUTHERFORD
Provider First Name:
BRENDA
Provider Middle Name:
RAE
Provider Name Prefix Text:
MRS.
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:
CRONK
Provider Other First Name:
BRENDA
Provider Other Middle Name:
RAE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154326874
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 NW NORTH RIDGE DRIVE, SUITE B
Provider Second Line Business Mailing Address:
ANESTHESIA SERVICES OF BLUE SPRINGS
Provider Business Mailing Address City Name:
BLUE SPRINGS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64015-6320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-988-8415
Provider Business Mailing Address Fax Number:
816-988-8395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 NW NORTH RIDGE DRIVE, SUITE B
Provider Second Line Business Practice Location Address:
ANESTHESIA SERVICES OF BLUE SPRINGS
Provider Business Practice Location Address City Name:
BLUE SPRINGS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64015-6320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-988-8415
Provider Business Practice Location Address Fax Number:
816-988-8395
Provider Enumeration Date:
06/17/2005

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:  R0081080 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 2002021268 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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