Basic Information
| Provider Information | |||||||||
| NPI: | 1710922729 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROVATIN | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 RIVER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108342828 | ||||||||
| FaxNumber: | 6108232862 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 SUNSET LN | ||||||||
| Address2: | |||||||||
| City: | CULPEPER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 227013917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408294100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0101051721 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6098011 | 05 | VA | MEDICAID |