Provider Demographics
NPI:1780673459
Name:GROOMS, RAYMOND JEFFERY (CRNA)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:JEFFERY
Last Name:GROOMS
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 1:122 RICE MILL DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-9073
Mailing Address - Country:US
Mailing Address - Phone:912-921-4719
Mailing Address - Fax:
Practice Address - Street 1:5500 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6236
Practice Address - Country:US
Practice Address - Phone:912-350-7219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN093384367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52782543OtherBCBS
GA52782543OtherBCBS