Basic Information
| Provider Information | |||||||||
| NPI: | 1811993769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOOMIS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7918 MAIN ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | FOGELSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180511744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103669536 | ||||||||
| FaxNumber: | 6103669538 | ||||||||
| Practice Location | |||||||||
| Address1: | 7918 MAIN STREET | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | FOGELSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180510488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103669536 | ||||||||
| FaxNumber: | 6103669538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 03/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN254017L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | RN-254017-L | PA | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 0019709940001 | 05 | PA | MEDICAID | 0019709940003 | 05 | PA | MEDICAID | 1553210 | 01 | PA | GATEWAY | OTHER | 11803037 | 01 | PA | CAQH | OTHER | 76114 | 01 | PA | GEISINGER | OTHER | 50014783 | 01 | PA | CAPITAL ADVANTAGE | OTHER | 7951477 | 01 | PA | AETNA | OTHER | 1406648 | 01 | PA | HIGHMARK | OTHER | 2094350000 | 01 | PA | IBC | OTHER | 1406648 | 01 | PA | FIRST PRIORITY | OTHER |