Provider Demographics
NPI:1073739439
Name:CRENSHAW FAMILY PRACTICE CLINIC, PC
Entity Type:Organization
Organization Name:CRENSHAW FAMILY PRACTICE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NEVILLE
Authorized Official - Middle Name:Q
Authorized Official - Last Name:CRENSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:660-727-3388
Mailing Address - Street 1:133 E MAIN
Mailing Address - Street 2:
Mailing Address - City:KAHOKA
Mailing Address - State:MO
Mailing Address - Zip Code:63445
Mailing Address - Country:US
Mailing Address - Phone:660-727-3388
Mailing Address - Fax:660-727-2196
Practice Address - Street 1:133 E MAIN
Practice Address - Street 2:
Practice Address - City:KAHOKA
Practice Address - State:MO
Practice Address - Zip Code:63445-1775
Practice Address - Country:US
Practice Address - Phone:660-727-3388
Practice Address - Fax:660-727-2196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242028900Medicaid
MO000002704OtherMEDICARE GROUP NUMBER
MOD41514Medicare UPIN
MO242028900Medicaid