Basic Information
| Provider Information | |||||||||
| NPI: | 1720079841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRITCHLOW | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1012 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638015044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734710330 | ||||||||
| FaxNumber: | 5734722966 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638015044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734710330 | ||||||||
| FaxNumber: | 5734722966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 05/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 25720 | MO | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207R00000X | R8486 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200384220 | 05 | MO | MEDICAID |