Basic Information
| Provider Information | |||||||||
| NPI: | 1750377347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODRUFF | ||||||||
| FirstName: | ALEXIS | ||||||||
| MiddleName: | CRANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5734 COVENTRY LANE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604367875 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5734 COVENTRY LANE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 458047141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604367875 | ||||||||
| FaxNumber: | 2604329812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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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 | 207L00000X | 35717 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 01062207 | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 35717 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64024441 | 05 | KY | MEDICAID |