Provider Demographics
NPI:1003912031
Name:CREVECOEUR, ROLAND JEAN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROLAND
Middle Name:JEAN
Last Name:CREVECOEUR
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N JUNIATA ST
Mailing Address - Street 2:P O BOX 632
Mailing Address - City:HOLLIDAYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16648-1997
Mailing Address - Country:US
Mailing Address - Phone:814-695-1675
Mailing Address - Fax:814-695-0632
Practice Address - Street 1:1800 N JUNIATA ST
Practice Address - Street 2:
Practice Address - City:HOLLIDAYSBURG
Practice Address - State:PA
Practice Address - Zip Code:16648-1997
Practice Address - Country:US
Practice Address - Phone:814-695-1675
Practice Address - Fax:814-695-0632
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419870207R00000X
PAMD-419870208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA110094OtherLEGACY PIN
PAP00432632OtherRR PIN
PA001922333Medicaid
PAP00432632OtherRR PIN