Provider Demographics
NPI:1053345561
Name:SMITH, CHARLES N (CRNA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:N
Last Name:SMITH
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 1:3366 RIVERSIDE DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221
Mailing Address - Country:US
Mailing Address - Phone:614-459-7830
Mailing Address - Fax:614-459-7824
Practice Address - Street 1:3130 N COUNTY ROAD 25A
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:614-459-7830
Practice Address - Fax:614-459-7824
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-123875367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0756383Medicaid
OH8205645Medicare ID - Type UnspecifiedMEDICARE PROVIDER #