1023054681 NPI number — DR. KENNETH CRABB M.D.

Table of content: DR. KENNETH CRABB M.D. (NPI 1023054681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023054681 NPI number — DR. KENNETH CRABB M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRABB
Provider First Name:
KENNETH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1023054681
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
280 SMITH AVE. NORTH
Provider Second Line Business Mailing Address:
SUITE 460
Provider Business Mailing Address City Name:
ST. PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55102-2437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-224-4897
Provider Business Mailing Address Fax Number:
651-297-6559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 SMITH AVE. NORTH
Provider Second Line Business Practice Location Address:
SUITE 460
Provider Business Practice Location Address City Name:
ST. PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55102-2437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-224-4897
Provider Business Practice Location Address Fax Number:
651-297-6559
Provider Enumeration Date:
06/21/2006

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: 174400000X , with the licence number:  22756 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 22756 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100613 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 675593300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00010438 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 21593CR . This is a "BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 07-29530 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP20169 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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