Basic Information
| Provider Information | |||||||||
| NPI: | 1326153396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CREW | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | GARY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163644200 | ||||||||
| FaxNumber: | 6163647347 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163644200 | ||||||||
| FaxNumber: | 6163647347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/03/2014 | ||||||||
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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 | 207L00000X | 5101009915 | MI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 4237171 | 05 | MI | MEDICAID |