Provider Demographics
NPI:1316915648
Name:MEITZNER, MARK (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MEITZNER
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 1:4054 CALUMET DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4713
Mailing Address - Country:US
Mailing Address - Phone:248-703-5742
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:400 FSC - PCS
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6769
Practice Address - Country:US
Practice Address - Phone:248-423-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704225319367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4631779Medicaid
MI430F364420OtherBCBSM
MIQ24946Medicare UPIN
MI0F36442288Medicare ID - Type Unspecified