Provider Demographics
NPI:1982661328
Name:RAFTERY, MARY (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RAFTERY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1934 DERBY RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-7530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30200 TELEGRAPH RD
Practice Address - Street 2:SUITE 220
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4502
Practice Address - Country:US
Practice Address - Phone:248-258-5058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704193821207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104566287Medicaid
MI104566287Medicaid
MAN78650009Medicare ID - Type UnspecifiedLOC 01