Basic Information
| Provider Information | |||||||||
| NPI: | 1396900882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROSSBOURNE | ||||||||
| FirstName: | ANEISHA | ||||||||
| MiddleName: | SELENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MBBS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CROSSBOURNE-MOSES | ||||||||
| OtherFirstName: | ANEISHA | ||||||||
| OtherMiddleName: | SELENE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MBBS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 250 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707966540 | ||||||||
| FaxNumber: | 2707966576 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 PARK ST | ||||||||
| Address2: | INPATIENT MEDICAL ASSOCIATES | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707966540 | ||||||||
| FaxNumber: | 2707966576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 01/24/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | TP879 | KY | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 44567 | KY | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.