Provider Demographics
NPI:1790730943
Name:HERNICZ, MICHAEL R (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:HERNICZ
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 187
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37892-0187
Mailing Address - Country:US
Mailing Address - Phone:423-569-6614
Mailing Address - Fax:
Practice Address - Street 1:4759 LAKEVIEW DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-2005
Practice Address - Country:US
Practice Address - Phone:863-402-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704104020367500000X
OH03992367500000X
FLARNP985972367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704104020OtherLICENSE NUMBER
FL8243542Medicare Oscar/Certification