Basic Information
| Provider Information | |||||||||
| NPI: | 1548751563 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAMES V. CRAWFORD, MD LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IDAHO EAR CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1209 N SUMMERBROOK AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836428750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089385823 | ||||||||
| FaxNumber: | 2089385306 | ||||||||
| Practice Location | |||||||||
| Address1: | 1209 N SUMMERBROOK AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836428750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089385823 | ||||||||
| FaxNumber: | 2089385306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2018 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | CRAWFORD | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2089385823 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0901X | M-14198 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology |
ID Information
| ID | Type | State | Issuer | Description | 1005083 | 05 | WA | MEDICAID |