1013540681 NPI number — MR. ELLWOOD CHARLES CROUSE III

Table of content: MR. ELLWOOD CHARLES CROUSE III (NPI 1013540681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013540681 NPI number — MR. ELLWOOD CHARLES CROUSE III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROUSE
Provider First Name:
ELLWOOD
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013540681
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 CLINTON AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOWER BURRELL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15068-2620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-996-9128
Provider Business Mailing Address Fax Number:
724-212-3595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 ALLEGHENY AVENUE
Provider Second Line Business Practice Location Address:
#204
Provider Business Practice Location Address City Name:
OAKMONT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15139-2059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-423-5445
Provider Business Practice Location Address Fax Number:
724-212-3595
Provider Enumeration Date:
02/21/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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