Provider Demographics
NPI:1033103452
Name:GLENN CROWSON MD INC
Entity Type:Organization
Organization Name:GLENN CROWSON MD INC
Other - Org Name:WEWOKA MEDICAL RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ALVIN
Authorized Official - Last Name:CROWSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-257-3396
Mailing Address - Street 1:PO BOX 1093
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884-1093
Mailing Address - Country:US
Mailing Address - Phone:405-257-3396
Mailing Address - Fax:405-257-6908
Practice Address - Street 1:1401 W 1ST ST
Practice Address - Street 2:
Practice Address - City:WEWOKA
Practice Address - State:OK
Practice Address - Zip Code:74884-5097
Practice Address - Country:US
Practice Address - Phone:405-257-3396
Practice Address - Fax:405-257-6908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13854207Q00000X, 261QR1300X
OKR0073222363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100740370BMedicaid
OK100156370AMedicaid
OK200015980AMedicaid
OK100740370CMedicaid
OK100156370AMedicaid
OK459600559Medicare ID - Type UnspecifiedPHYSICIAN MEDICARE B
OK100740370BMedicaid
OKC94817Medicare UPIN
OK400522089Medicare ID - Type UnspecifiedGROUP MEDICARE
OK373825Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC