Provider Demographics
NPI:1972504801
Name:GUND, MICHAEL W (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:GUND
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 1351
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-1351
Mailing Address - Country:US
Mailing Address - Phone:800-235-1415
Mailing Address - Fax:913-234-1108
Practice Address - Street 1:1808 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2724
Practice Address - Country:US
Practice Address - Phone:479-968-2841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00865367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S503OtherBLUE CROSS BLUE SHIELD AR
AR125162701Medicaid
430024065OtherRR MEDICARE GROUP CC5970
AR5S503Medicare PIN
AR5S503OtherBLUE CROSS BLUE SHIELD AR