Provider Demographics
NPI:1770641961
Name:GREATHOUSE, JEFFREY STEPHEN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:STEPHEN
Last Name:GREATHOUSE
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 1:675 THOROFARE ROAD
Mailing Address - Street 2:
Mailing Address - City:CLENDENIN
Mailing Address - State:WV
Mailing Address - Zip Code:25045
Mailing Address - Country:US
Mailing Address - Phone:304-388-6220
Mailing Address - Fax:304-388-3604
Practice Address - Street 1:501 MORRIS STREET
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:304-388-6220
Practice Address - Fax:304-388-3604
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26781163W00000X
WV33938367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0065010000Medicaid
WVGR7115741Medicare ID - Type Unspecified