Provider Demographics
NPI:1508825308
Name:MCNUTT, SAMUEL HAL JR (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:HAL
Last Name:MCNUTT
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:293 GREYSTONE BLVD
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-8004
Mailing Address - Country:US
Mailing Address - Phone:803-296-2548
Mailing Address - Fax:803-296-2548
Practice Address - Street 1:TAYLOR AT MARION STREETS
Practice Address - Street 2:PALMETTO HEALTH BAPTIST
Practice Address - City:RICHLAND
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-296-2548
Practice Address - Fax:803-296-2548
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC150367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0522Medicaid
SCQ27572Medicare PIN
SCAN0522Medicaid