Basic Information
| Provider Information | |||||||||
| NPI: | 1376702241 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROCKETT | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7590 AUBURN RD STE 14 | ||||||||
| Address2: | |||||||||
| City: | CONCORD TWP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440779176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403541899 | ||||||||
| FaxNumber: | 4403541845 | ||||||||
| Practice Location | |||||||||
| Address1: | 5105 SOM CENTER ROAD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406026710 | ||||||||
| FaxNumber: | 4402698107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 34.009381 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 58.001481 | OH | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2867858 | 05 | OH | MEDICAID |