Individual
ROBERT J IDACAVAGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
618 S MAIN ST, REIDSVILLE, NC 27320-5020
(336) 951-4000
Mailing address
PO BOX 26580, GREENSBORO, NC 27415-6580
(336) 832-7786
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
39472
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8052514
—
NC
Enumeration date
01/04/2007
Last updated
07/08/2007
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