Basic Information
| Provider Information | |||||||||
| NPI: | 1457332785 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROCK | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7072 MEARS GATE DR NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447208850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309661319 | ||||||||
| FaxNumber: | 3309661321 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 MERCY DR NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447082614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304891000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0002X | 35066830C | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 207R00000X | 35066830C | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2157366 | 01 | OH | GROUP MEDICAID - MPCC | OTHER | 1376559799 | 01 | OH | GROUP NPI | OTHER | 1902827876 | 01 | GROUP NPI - MPCC | OTHER | 0142081 | 05 | OH | MEDICAID | 2157320 | 01 | GROUP MEDICAID | OTHER | ME9303389 | 01 | OH | GROUP MEDICARE - MPCC | OTHER |