1275657462 NPI number — MR. PAUL ALAN CROUCH OTR

Table of content: MR. PAUL ALAN CROUCH OTR (NPI 1275657462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275657462 NPI number — MR. PAUL ALAN CROUCH OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROUCH
Provider First Name:
PAUL
Provider Middle Name:
ALAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OTR
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:
1275657462
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
788 FOXLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOOD RIVER
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97031-9722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-806-0047
Provider Business Mailing Address Fax Number:
541-386-3868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
788 FOXLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOOD RIVER
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97031-9722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-806-0047
Provider Business Practice Location Address Fax Number:
541-386-3868
Provider Enumeration Date:
03/16/2007

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:  1021091 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: OT00002839 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 023087 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7683501 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 337703 . This is a "PROVIDENCE HEALTH NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 71981 . This is a "HEALTHSCAPE PROVIDER NUM" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 840393000 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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