Basic Information
| Provider Information | |||||||||
| NPI: | 1598723959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROWDER | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | SLADE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 775383 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606775383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123753000 | ||||||||
| FaxNumber: | 8123753477 | ||||||||
| Practice Location | |||||||||
| Address1: | 3203 MIDDLE ROAD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123732700 | ||||||||
| FaxNumber: | 8123732710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01057432A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000984083 | 01 | IN | ANTHEM PIN | OTHER | P00038722 | 01 | IN | MEDICARE RAILROAD | OTHER | 200426270A | 05 | IN | MEDICAID | 000000286084 | 01 | IN | BLUE CROSS ANTHEM | OTHER | 01057432A | 01 | IN | IN MEDICAL LICENSE | OTHER | 1407861164 | 01 | GROUP NPI | OTHER |