Provider Demographics
NPI:1144236274
Name:ZANDER, ROGER W (CRNA)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:W
Last Name:ZANDER
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 1:22211 MORLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2110
Mailing Address - Country:US
Mailing Address - Phone:313-492-5056
Mailing Address - Fax:313-565-8156
Practice Address - Street 1:22211 MORLEY AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2110
Practice Address - Country:US
Practice Address - Phone:313-492-5056
Practice Address - Fax:313-565-8156
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704118315367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104329540Medicaid
MIRZ118315OtherBLUE CROSS OF MI
MI430068425Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MIN24360129Medicare ID - Type Unspecified