Provider Demographics
NPI:1780757351
Name:PELL, ROGER JACK (CRNA)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:JACK
Last Name:PELL
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 1:5833 ROWLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-2217
Mailing Address - Country:US
Mailing Address - Phone:248-674-0501
Mailing Address - Fax:248-674-0501
Practice Address - Street 1:50 N PERRY ST
Practice Address - Street 2:DEPARTMENT OF ANESTHESIA ATTN KAREN SANDERSON
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-2217
Practice Address - Country:US
Practice Address - Phone:248-338-5442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704155121367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered