Basic Information
| Provider Information | |||||||||
| NPI: | 1730208893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOUGLAS CRUTCHER, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 870 CORPORATE DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405035416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592779436 | ||||||||
| FaxNumber: | 8592771765 | ||||||||
| Practice Location | |||||||||
| Address1: | 1210 KY HWY 36E | ||||||||
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| City: | CYNTHIANA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410317490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592779436 | ||||||||
| FaxNumber: | 8592771765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | CRUTCHER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8592779436 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 22755 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 65931057 | 05 | KY | MEDICAID |