Provider Demographics
NPI:1568572063
Name:FRIEDBERG, MARC ALAN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ALAN
Last Name:FRIEDBERG
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 1:604 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-5404
Mailing Address - Country:US
Mailing Address - Phone:540-951-0259
Mailing Address - Fax:
Practice Address - Street 1:CARILION PROFESSIONAL SERVICES
Practice Address - Street 2:BELLEVIEW AVE AT JEFFERSON ST S.E.
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1850
Practice Address - Country:US
Practice Address - Phone:540-981-8310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX516732367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010363667Medicaid
TX516732OtherREGISTERED NURSE LIC/TX
VA010363683Medicaid
VA010363713Medicaid
VA010363748Medicaid
043194OtherCRNA
VA010363624Medicaid
011731C37Medicare PIN