Provider Demographics
NPI:1376775718
Name:CROSSROADS MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CROSSROADS MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTINE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-477-6888
Mailing Address - Street 1:3028 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2640
Mailing Address - Country:US
Mailing Address - Phone:219-477-6888
Mailing Address - Fax:219-477-6804
Practice Address - Street 1:3028 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2640
Practice Address - Country:US
Practice Address - Phone:219-477-6888
Practice Address - Fax:219-477-6804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-19
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty