Provider Demographics
NPI:1871548222
Name:JUSZCZAK, THADDEUS F (CRNA)
Entity type:Individual
Prefix:
First Name:THADDEUS
Middle Name:F
Last Name:JUSZCZAK
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 1:701 S HEALTH PKWY
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-8352
Mailing Address - Country:US
Mailing Address - Phone:269-273-9789
Mailing Address - Fax:269-273-9611
Practice Address - Street 1:701 S HEALTH PKWY
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8352
Practice Address - Country:US
Practice Address - Phone:269-278-1145
Practice Address - Fax:269-273-9611
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704106613367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4893487-10Medicaid
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH
MI0G51062OtherBCBS
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH
MI4893487-10Medicaid