Provider Demographics
NPI:1609856657
Name:ROEHM, MARY ETHEL (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ETHEL
Last Name:ROEHM
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 1:8 AUTUMN OAK WAY
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-4066
Mailing Address - Country:US
Mailing Address - Phone:864-836-6151
Mailing Address - Fax:864-836-6157
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:STE B 100
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-451-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR59124163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse