Basic Information
| Provider Information | |||||||||
| NPI: | 1952352908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROOM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4400 BROADWAY | ||||||||
| Address2: | SUITE 520 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641113498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165314080 | ||||||||
| FaxNumber: | 8165310281 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 BROADWAY | ||||||||
| Address2: | SUITE 520 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641113498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165314080 | ||||||||
| FaxNumber: | 8165310281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 2006004083 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 04-31775 | KS | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 200381380A | 05 | KS | MEDICAID | 200644508 | 05 | MO | MEDICAID | 36305017 | 01 | BCBS | OTHER | 7438509 | 01 | AETNA | OTHER | 200381380B | 05 | KS | MEDICAID |