Provider Demographics
NPI:1366486896
Name:WILLIAMS, BLAINE R (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:R
Last Name:WILLIAMS
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 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8419
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:125 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5239
Practice Address - Country:US
Practice Address - Phone:269-343-1381
Practice Address - Fax:269-343-6321
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704101145367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI430C910670OtherBCBS GRP PIN
MI4308752210OtherBCBS IND PIN
5453510OtherAETNA PIN
383148262OtherEIN-HEALTHCARE MIDWEST
5453510OtherAETNA PIN
MI0N11350011Medicare ID - Type Unspecified