Basic Information
| Provider Information | |||||||||
| NPI: | 1902156839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRAWCZUK | ||||||||
| FirstName: | LINDSEY | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GADDIS | ||||||||
| OtherFirstName: | LINDSEY | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4046 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658084046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172695712 | ||||||||
| FaxNumber: | 4172697567 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 S. NATIONAL AVE. | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172699812 | ||||||||
| FaxNumber: | 4172699853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2012 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 1875751164 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 2017011897 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200045728 | 05 | MO | MEDICAID |