Provider Demographics
NPI:1770537169
Name:DURDEN, PHILIP B (CRNA)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:B
Last Name:DURDEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:05444 BEECHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-7797
Mailing Address - Country:US
Mailing Address - Phone:574-268-9640
Mailing Address - Fax:574-268-0684
Practice Address - Street 1:955 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-9701
Practice Address - Country:US
Practice Address - Phone:269-637-5271
Practice Address - Fax:269-639-2818
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704231742367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI430C910670OtherBLUE CROSS BLUE SHIELD
MI430C910670OtherBLUE CROSS BLUE SHIELD
MIOH06003Medicare PIN
MIM77150101Medicare PIN
MI430C910670OtherBLUE CROSS BLUE SHIELD