Basic Information
| Provider Information | |||||||||
| NPI: | 1437243938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROUCH | ||||||||
| FirstName: | RENITA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 NORTH EAGLE CREEK DRIVE | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592585300 | ||||||||
| FaxNumber: | 8592585357 | ||||||||
| Practice Location | |||||||||
| Address1: | UK SURGERY CLINIC - CARDIOTHORACIC | ||||||||
| Address2: | 740 S LIMESTONE STE L304 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593236494 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA096 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | PA096 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA096 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 37903705 | 01 | KY | MEDICAID LAB GROUP | OTHER | 95002556 | 05 | KY | MEDICAID | 970025767 | 01 | GA | RR MEDICARE PIN | OTHER | CB5773 | 01 | GA | RR MEDICARE GROUP | OTHER | 4000501 | 01 | KY | MEDICARE LAB GROUP | OTHER |