Provider Demographics
NPI:1639163942
Name:HARSCH, TERRI (CRNA)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:HARSCH
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 1:556 N SHORE DR LOT 3
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-1062
Mailing Address - Country:US
Mailing Address - Phone:435-174-1211
Mailing Address - Fax:
Practice Address - Street 1:556 N SHORE DR LOT 3
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-1062
Practice Address - Country:US
Practice Address - Phone:435-174-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5053564-4405367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4416Medicaid
MI0F76004OtherBCBSM
UT50535644400001OtherBXBS
UT50535644400001OtherBXBS
UT005582321Medicare ID - Type Unspecified
MI0F76004OtherBCBSM