Provider Demographics
NPI:1710561147
Name:RAYMOND, MATTHEW EDWARD (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EDWARD
Last Name:RAYMOND
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 1:105 SHARPSBURG CIR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35213-1712
Mailing Address - Country:US
Mailing Address - Phone:334-590-1431
Mailing Address - Fax:
Practice Address - Street 1:3690 GRANDVIEW PKWY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-3326
Practice Address - Country:US
Practice Address - Phone:205-971-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-168114163W00000X
AL133598367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse