Provider Demographics
NPI:1508031295
Name:CRAWFORD SURGICARE
Entity Type:Organization
Organization Name:CRAWFORD SURGICARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-582-7100
Mailing Address - Street 1:6441 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-5148
Mailing Address - Country:US
Mailing Address - Phone:773-582-7100
Mailing Address - Fax:773-561-1111
Practice Address - Street 1:6441 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5148
Practice Address - Country:US
Practice Address - Phone:773-582-7100
Practice Address - Fax:773-561-1111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:W JACOBSEN DPM PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004485261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric