Provider Demographics
NPI:1710989710
Name:DOVE, HAVEN (CRNA)
Entity Type:Individual
Prefix:
First Name:HAVEN
Middle Name:
Last Name:DOVE
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 151
Mailing Address - Street 2:1100 MERCER AVE.
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733-0151
Mailing Address - Country:US
Mailing Address - Phone:260-724-2145
Mailing Address - Fax:
Practice Address - Street 1:1100 MERCER AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-2303
Practice Address - Country:US
Practice Address - Phone:260-724-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28143888367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCC7080CMedicare PIN