Provider Demographics
NPI:1669436697
Name:NEAL, JODY RUSSELL (CRNA)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:RUSSELL
Last Name:NEAL
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 6907
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302
Mailing Address - Country:US
Mailing Address - Phone:334-793-5000
Mailing Address - Fax:334-615-8419
Practice Address - Street 1:4370 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305
Practice Address - Country:US
Practice Address - Phone:334-793-5000
Practice Address - Fax:334-615-8419
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1068484367500000X
GARN161608367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01138875Medicaid
2000600OtherUNITED HEALTHCARE
P00122085OtherRR MCARE
LA1771392Medicaid
AL051515690Medicaid
FL303304000Medicaid
AL51515690OtherBLUE CROSS BLUE SHIELD AL
GA000891371CMedicaid
LA1771392Medicaid
GA000891371CMedicaid