1851393623 NPI number — GARY A DERAAD CRNA

Table of content: GARY A DERAAD CRNA (NPI 1851393623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851393623 NPI number — GARY A DERAAD CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERAAD
Provider First Name:
GARY
Provider Middle Name:
A
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:
1851393623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26699 MOHAWK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PERRYSBURG
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43551-5403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-690-7652
Provider Business Mailing Address Fax Number:
419-697-7726

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 BAY PARK DR
Provider Second Line Business Practice Location Address:
DEPARTMENT OF SURGERY
Provider Business Practice Location Address City Name:
OREGON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43616-4920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-690-7652
Provider Business Practice Location Address Fax Number:
419-697-7726
Provider Enumeration Date:
08/11/2005

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:  4238A , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: RN 279724 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00619434 . This is a "RRMC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000556304 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 341881145-003 . This is a "MMO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 04097A . This is a "PARAMOUNT" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 5182096 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 74007279 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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