Provider Demographics
NPI:1811044530
Name:IDACAVAGE, ROBERT J (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:IDACAVAGE
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 26580
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415-6580
Mailing Address - Country:US
Mailing Address - Phone:336-832-7786
Mailing Address - Fax:
Practice Address - Street 1:618 S MAIN ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5020
Practice Address - Country:US
Practice Address - Phone:336-951-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39472367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052514Medicaid
NC8052514Medicaid