Basic Information
| Provider Information | |||||||||
| NPI: | 1386990638 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROUSE MEDICAL PRACTICE PLLC | ||||||||
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| OtherOrganizationName: | SPORTS CARE EXPRESS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91004 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146929104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154463904 | ||||||||
| FaxNumber: | 3155526590 | ||||||||
| Practice Location | |||||||||
| Address1: | 5823 WIDEWATERS PKWY | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130573081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154746824 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2012 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | KRONENBERG | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE SHAREHOLDER | ||||||||
| AuthorizedOfficialTelephone: | 3154707825 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CROUSE MEDICAL PRACTICE PLLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 363A00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.