Basic Information
Provider Information | |||||||||
NPI: | 1003854365 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CROWELL | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WOUDENBERG MECKLER | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 25 COMMUNICATIONS WAY | ||||||||
Address2: | MACC-REVENUE CYCLE | ||||||||
City: | HYANNIS | ||||||||
State: | MA | ||||||||
PostalCode: | 026011866 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5089578664 | ||||||||
FaxNumber: | 5089578677 | ||||||||
Practice Location | |||||||||
Address1: | 1030 FALMOUTH RD | ||||||||
Address2: |   | ||||||||
City: | HYANNIS | ||||||||
State: | MA | ||||||||
PostalCode: | 026012324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7744705080 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2006 | ||||||||
LastUpdateDate: | 05/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 217447 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | AA8103 | 01 | MA | HP HC | OTHER | 2023580 | 05 | MA |   | MEDICAID | J26912 | 01 | MA | BCBS | OTHER |