1568572063 NPI number — MARC ALAN FRIEDBERG CRNA

Table of content: MARC ALAN FRIEDBERG CRNA (NPI 1568572063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568572063 NPI number — MARC ALAN FRIEDBERG CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRIEDBERG
Provider First Name:
MARC
Provider Middle Name:
ALAN
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:
1568572063
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
604 AIRPORT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLACKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24060-5404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-951-0259
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARILION PROFESSIONAL SERVICES
Provider Second Line Business Practice Location Address:
BELLEVIEW AVE AT JEFFERSON ST S.E.
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24014-1850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-981-8310
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2006

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:  516732 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010363667 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 516732 . This is a "REGISTERED NURSE LIC/TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 010363683 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010363713 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010363748 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 043194 . This is a "CRNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010363624 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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