Basic Information
| Provider Information | |||||||||
| NPI: | 1669465936 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROSSAN | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 62647 COLLECTION CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606930626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737264713 | ||||||||
| FaxNumber: | 8159412476 | ||||||||
| Practice Location | |||||||||
| Address1: | 19060 EVERETT BLVD | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604481942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084784302 | ||||||||
| FaxNumber: | 7084784303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 036114158 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 036114158 | 05 | IL | MEDICAID |