Basic Information
| Provider Information | |||||||||
| NPI: | 1992733091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROSSMAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3875 NEW HOLLAND ST | ||||||||
| Address2: | |||||||||
| City: | HUDSONVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494261670 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 560 5TH ST NW | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495045219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163565000 | ||||||||
| FaxNumber: | 6163565001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 05/16/2008 | ||||||||
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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 | 225100000X | 5501003422 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 650E410320 | 01 | MI | BCBSM | OTHER | 650G011770 | 01 | MI | BCBS | OTHER | 1992733091 | 01 | MI | NPI | OTHER | 5501003422 | 01 | MI | STATE OF MICHIGAN | OTHER | 236850 | 01 | MI | MDCR FACILITY NUMBER | OTHER |