Basic Information
| Provider Information | |||||||||
| NPI: | 1194717397 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CREQUE | ||||||||
| FirstName: | RON | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 STONECREST ROAD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026335565 | ||||||||
| FaxNumber: | 5026335154 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 STONECREST ROAD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026335565 | ||||||||
| FaxNumber: | 5026335154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| 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 | 207Q00000X | 36516 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000200138 | 01 | ANTHEM | OTHER | 64030653 | 05 | KY | MEDICAID |