Provider Demographics
NPI:1598723959
Name:CROWDER, JONATHAN SLADE (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SLADE
Last Name:CROWDER
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:PO BOX 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-375-3000
Mailing Address - Fax:812-375-3477
Practice Address - Street 1:3203 MIDDLE ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203
Practice Address - Country:US
Practice Address - Phone:812-373-2700
Practice Address - Fax:812-373-2710
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057432A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000984083OtherANTHEM PIN
INP00038722OtherMEDICARE RAILROAD
IN200426270AMedicaid
IN000000286084OtherBLUE CROSS ANTHEM
IN01057432AOtherIN MEDICAL LICENSE
1407861164OtherGROUP NPI
INP00038722OtherMEDICARE RAILROAD
IN200426270AMedicaid
ININ2762073Medicare PIN