Basic Information
| Provider Information | |||||||||
| NPI: | 1679648323 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROMWELL | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 CHERRY AVENUE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604792360 | ||||||||
| FaxNumber: | 3604794038 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 CHERRY AVENUE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604792360 | ||||||||
| FaxNumber: | 3604794038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207X00000X | MD00013823 | WA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | AC7578454 | 01 | DRUG ENFORCEMENT AGENCY | OTHER | MD00013823 | 01 | WA | WA STATE MED | OTHER | 1220805 | 05 | WA | MEDICAID |