1376702241 NPI number — DR. REBECCA ELIZABETH CROCKETT DO

Table of content: DR. REBECCA ELIZABETH CROCKETT DO (NPI 1376702241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376702241 NPI number — DR. REBECCA ELIZABETH CROCKETT DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROCKETT
Provider First Name:
REBECCA
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1376702241
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7590 AUBURN RD STE 14
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONCORD TWP
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44077-9176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-354-1899
Provider Business Mailing Address Fax Number:
440-354-1845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5105 SOM CENTER ROAD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
WILLOUGHBY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-602-6710
Provider Business Practice Location Address Fax Number:
440-269-8107
Provider Enumeration Date:
06/05/2008

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: 207V00000X , with the licence number:  34.009381 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: 58.001481 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2867858 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com