Provider Demographics
NPI:1558631093
Name:JONATHAN CROMWELL D.C., P.C.
Entity Type:Organization
Organization Name:JONATHAN CROMWELL D.C., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:CROMWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-477-1492
Mailing Address - Street 1:23280 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-3100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23280 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3100
Practice Address - Country:US
Practice Address - Phone:248-477-1492
Practice Address - Fax:248-474-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-30
Last Update Date:2012-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005887111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2831233Medicaid
MI950F35388OtherBLUE CROSS BLUE SHIELD OF MICIGAN
U30477Medicare UPIN