Provider Demographics
NPI:1326050790
Name:MERIDIAN CRNA LLC
Entity Type:Organization
Organization Name:MERIDIAN CRNA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FUNCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-485-6325
Mailing Address - Street 1:4700 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-4706
Mailing Address - Country:US
Mailing Address - Phone:601-485-6325
Mailing Address - Fax:601-485-3061
Practice Address - Street 1:4700 26TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-4706
Practice Address - Country:US
Practice Address - Phone:601-485-6325
Practice Address - Fax:601-485-3061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07883328Medicaid
MSC03514Medicare PIN