Provider Demographics
NPI:1700848512
Name:WHOBERRY, MICHAEL E (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:WHOBERRY
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:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-0032
Mailing Address - Country:US
Mailing Address - Phone:812-254-2760
Mailing Address - Fax:812-254-8636
Practice Address - Street 1:1314 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-2120
Practice Address - Country:US
Practice Address - Phone:812-254-2760
Practice Address - Fax:812-254-8636
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28066860A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200195480Medicaid
IN000000190468OtherANTHEM
R17171Medicare UPIN
INCB2060BMedicare ID - Type Unspecified
IN430064801Medicare PIN