Basic Information
Provider Information | |||||||||
NPI: | 1457301319 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CATHERINE A KROLL, DO,PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1330 | ||||||||
Address2: |   | ||||||||
City: | GWINN | ||||||||
State: | MI | ||||||||
PostalCode: | 498411330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9063469275 | ||||||||
FaxNumber: | 9063465161 | ||||||||
Practice Location | |||||||||
Address1: | 135 E. M-35 | ||||||||
Address2: |   | ||||||||
City: | GWINN | ||||||||
State: | MI | ||||||||
PostalCode: | 49841 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9063469275 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2006 | ||||||||
LastUpdateDate: | 05/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KROLL | ||||||||
AuthorizedOfficialFirstName: | CATHERINE | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9063469275 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101008621 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0805210582 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER | 104839571 | 05 | MI |   | MEDICAID | 085520052 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER | 113395739 | 05 | MI |   | MEDICAID |