1750373247 NPI number — JACK W CROSLAND MD

Table of content: JACK W CROSLAND MD (NPI 1750373247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750373247 NPI number — JACK W CROSLAND MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROSLAND
Provider First Name:
JACK
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1750373247
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2240 ADAMS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OGDEN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84401-1511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-393-5355
Provider Business Mailing Address Fax Number:
801-394-4609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2240 ADAMS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84401-1511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-393-5355
Provider Business Practice Location Address Fax Number:
801-394-4609
Provider Enumeration Date:
08/19/2005

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: 207X00000X , with the licence number:  159595-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: QM000053820 . This is a "ALTIUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 870680455007 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 870680455CRO . This is a "EDUCATORS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 05391 . This is a "MHB" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6273 . This is a "DMBA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 107004879101 . This is a "IHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 68969 . This is a "PEHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 810680455A005 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".




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