Provider Demographics
NPI:1598862138
Name:FISHMAN, MARY SUSAN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:FISHMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1661
Mailing Address - Country:US
Mailing Address - Phone:270-825-5100
Mailing Address - Fax:
Practice Address - Street 1:900 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1644
Practice Address - Country:US
Practice Address - Phone:270-825-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3000699367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY699AOtherLICENSE
000000044289OtherBCBS PIN
KY74349499Medicaid
KYP400020190Medicare PIN
0374539Medicare PIN
000000044289OtherBCBS PIN
KY74349499Medicaid