Basic Information
| Provider Information | |||||||||
| NPI: | 1700881174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROWDER | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT CH 14389 | ||||||||
| Address2: | |||||||||
| City: | PALATINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600554389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852955307 | ||||||||
| FaxNumber: | 7852707646 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 SW 7TH ST | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666062489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852958359 | ||||||||
| FaxNumber: | 7852315988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 01/29/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/17/2006 | ||||||||
| NPIReactivationDate: | 03/23/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 04-33925 | KS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 04-33925 | KS | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 200258860B | 05 | KS | MEDICAID |