Provider Demographics
NPI:1114023397
Name:STROMBERG, MARK V (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:V
Last Name:STROMBERG
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 1:10000 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3330
Mailing Address - Country:US
Mailing Address - Phone:313-295-5103
Mailing Address - Fax:313-295-5363
Practice Address - Street 1:10000 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3330
Practice Address - Country:US
Practice Address - Phone:313-295-5103
Practice Address - Fax:313-295-5363
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704121139367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4310979Medicaid