Provider Demographics
NPI:1942200381
Name:SWINGHOLM, JEFFREY H (CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:H
Last Name:SWINGHOLM
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 1019
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1019
Mailing Address - Country:US
Mailing Address - Phone:304-257-1026
Mailing Address - Fax:304-257-1932
Practice Address - Street 1:C/O GRANT MEMORIAL HOSPITAL
Practice Address - Street 2:1 HOSPITAL DRIVE
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847
Practice Address - Country:US
Practice Address - Phone:304-257-1026
Practice Address - Fax:304-257-1932
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV59659367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2605108000Medicaid
WV2605108000Medicaid
WVSW7318151Medicare ID - Type UnspecifiedMEDICARE