Provider Demographics
NPI:1124116181
Name:DESGRANDCHAMP, MILTON JAMES (CRNA)
Entity type:Individual
Prefix:MR
First Name:MILTON
Middle Name:JAMES
Last Name:DESGRANDCHAMP
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36775
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48236-0775
Mailing Address - Country:US
Mailing Address - Phone:313-530-6603
Mailing Address - Fax:
Practice Address - Street 1:255 LEWISTON RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3450
Practice Address - Country:US
Practice Address - Phone:313-530-6603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704158813367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered