1164417960 NPI number — MICHAEL WALSH CRNA

Table of content: MICHAEL WALSH CRNA (NPI 1164417960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164417960 NPI number — MICHAEL WALSH CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALSH
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

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:
1164417960
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
165 2ND ST W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33715-1710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-867-5722
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 N ROBERTS AVE
Provider Second Line Business Practice Location Address:
DESOTO MEMORIAL HOSPITAL
Provider Business Practice Location Address City Name:
ARCADIA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34266-8765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-494-8475
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2005

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:  ARNP2643722 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00420652 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com