Basic Information
| Provider Information | |||||||||
| NPI: | 1902992050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRANICK | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | WESLEY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3988 | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629023988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004575200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 S 14TH ST | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629483631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189422171 | ||||||||
| FaxNumber: | 6183514917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 085-002739 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 363A00000X | PA9103859 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 0010-00923 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 085-002739 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 214881 | 01 | IL | MEDICARE OSCAR | OTHER | 3932056 | 01 | IL | BLUE SHIELD | OTHER |