Basic Information
| Provider Information | |||||||||
| NPI: | 1033259361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRILL | ||||||||
| FirstName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 COMMERCE DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480593819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103858086 | ||||||||
| FaxNumber: | 8103854933 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 PINE GROVE AVE | ||||||||
| Address2: | PORT HURON HOSPITAL EMERGENCY DEPT | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109875000 | ||||||||
| FaxNumber: | 8103854933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301084158 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4301084158 | 01 | MI | LICENSE | OTHER |