1053580167 NPI number — CROW CREEK THERAPEUTICS, LLC

Table of content: (NPI 1053580167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053580167 NPI number — CROW CREEK THERAPEUTICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROW CREEK THERAPEUTICS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1053580167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
580 S HIGH ST
Provider Second Line Business Mailing Address:
STE 230
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43215-5644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-420-2337
Provider Business Mailing Address Fax Number:
866-228-9250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1740 HARMON AVE
Provider Second Line Business Practice Location Address:
STE H
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43223-3355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-420-2337
Provider Business Practice Location Address Fax Number:
866-228-5570
Provider Enumeration Date:
02/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SAKON
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
888-420-2337

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1752867 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000581418 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2850197 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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