Basic Information
| Provider Information | |||||||||
| NPI: | 1194040048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUTHIRD | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRUTHIRD-RUDD | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4016 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466344016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742333123 | ||||||||
| FaxNumber: | 5742333125 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 S SAINT LOUIS BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466172924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742333123 | ||||||||
| FaxNumber: | 5742333125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2010 | ||||||||
| LastUpdateDate: | 11/26/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01073502A | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 201228320 | 05 | IN | MEDICAID |