Provider Demographics
NPI:1629056650
Name:MIELKE, ROBERT H (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:H
Last Name:MIELKE
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 1:209 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-5831
Mailing Address - Country:US
Mailing Address - Phone:573-686-5550
Mailing Address - Fax:573-686-2139
Practice Address - Street 1:209 S MAIN ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-5831
Practice Address - Country:US
Practice Address - Phone:573-686-5550
Practice Address - Fax:573-686-2139
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO063979367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00165165OtherRAILROAD MEDICARE
MO184883OtherIND BCBS
MO912876216Medicaid
MO001014008Medicare PIN
MO912876216Medicaid