Provider Demographics
NPI:1518996438
Name:DYKE, MARC MITCHELL (CRNA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:MITCHELL
Last Name:DYKE
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:PO BOX 12938
Mailing Address - Street 2:C/O CLINIC MANAGEMENT
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1035 RED BUD RD NE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-6008
Practice Address - Country:US
Practice Address - Phone:706-879-4776
Practice Address - Fax:706-879-5841
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN096589367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000550877JMedicaid
GA000550877KMedicaid
GA344889OtherWELLCARE
GAGRP 332OtherMEDICARE GRP NUMBER
GA430061380OtherRAILROAD MEDICARE PART B
GA004443OtherBLUECROSS BLUE SHIELD
GACM 5659OtherRAILROAD GRP NUMBER
GA43ZCBNL09OtherMEDICARE PROVIDER NUMBER