Provider Demographics
NPI:1033188990
Name:BEREDO, MICHAEL D (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:BEREDO
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:570-887-4464
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN542206367500000X
NY538854-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC8362OtherRR MEDICARE GROUP
NYP00379063OtherRR MEDICARE PIN
PA430078581OtherRR MEDICARE PIN
PAGU039832OtherMEDICARE GROUP
PACC9269OtherRR MEDICARE GROUP
PA430078581OtherRR MEDICARE PIN
PACC9269OtherRR MEDICARE GROUP