Provider Demographics
NPI:1811993769
Name:LOOMIS, MICHAEL C (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:LOOMIS
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 1:7918 MAIN ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FOGELSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18051-1744
Mailing Address - Country:US
Mailing Address - Phone:610-366-9536
Mailing Address - Fax:610-366-9538
Practice Address - Street 1:7918 MAIN STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:FOGELSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18051-0488
Practice Address - Country:US
Practice Address - Phone:610-366-9536
Practice Address - Fax:610-366-9538
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN254017L367500000X
PARN-254017-L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019709940001Medicaid
PA0019709940003Medicaid
PA1553210OtherGATEWAY
PA11803037OtherCAQH
PA76114OtherGEISINGER
PA50014783OtherCAPITAL ADVANTAGE
PA7951477OtherAETNA
PA1406648OtherHIGHMARK
PA2094350000OtherIBC
PA1406648OtherFIRST PRIORITY
PA0019709940003Medicaid
PA1406648OtherFIRST PRIORITY
PA0019709940001Medicaid
PA005368Medicare PIN