Provider Demographics
NPI:1407967771
Name:CRUTCHER, COLIE (MD)
Entity Type:Individual
Prefix:
First Name:COLIE
Middle Name:
Last Name:CRUTCHER
Suffix:
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 1:754 DERBY DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:AL
Mailing Address - Zip Code:36925-2122
Mailing Address - Country:US
Mailing Address - Phone:205-392-5350
Mailing Address - Fax:205-392-4821
Practice Address - Street 1:754 DERBY DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:AL
Practice Address - Zip Code:36925-2122
Practice Address - Country:US
Practice Address - Phone:205-392-5350
Practice Address - Fax:205-392-4821
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17070174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000025938Medicaid
AL000025938Medicaid