Provider Demographics
NPI:1083722284
Name:KRUCHOWSKY, TIMOTHY JOSEPH (PT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:KRUCHOWSKY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12958 COLES CV
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-5620
Mailing Address - Country:US
Mailing Address - Phone:228-831-9480
Mailing Address - Fax:
Practice Address - Street 1:1500 45TH AVE STE B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-3714
Practice Address - Country:US
Practice Address - Phone:228-864-1212
Practice Address - Fax:228-868-2323
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0843MS225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124330Medicaid
MS00124330Medicaid