Provider Demographics
| NPI: | 1609093228 |
|---|---|
| Name: | CROUCH FAMILY MEDICINE PC |
| Entity Type: | Organization |
| Organization Name: | CROUCH FAMILY MEDICINE PC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | BUSINESS MANAGER |
| Authorized Official - Prefix: | MRS |
| Authorized Official - First Name: | ROBIN |
| Authorized Official - Middle Name: | LEE |
| Authorized Official - Last Name: | CROUCH |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 405-258-9955 |
| Mailing Address - Street 1: | 806 MANVEL AVE |
| Mailing Address - Street 2: | |
| Mailing Address - City: | CHANDLER |
| Mailing Address - State: | OK |
| Mailing Address - Zip Code: | 74834-3858 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 405-258-9955 |
| Mailing Address - Fax: | 405-258-9930 |
| Practice Address - Street 1: | 806 MANVEL AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | CHANDLER |
| Practice Address - State: | OK |
| Practice Address - Zip Code: | 74834-3858 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 405-258-9955 |
| Practice Address - Fax: | 405-258-9930 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2007-04-18 |
| Last Update Date: | 2013-03-04 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| OK | 4290 | 261QP2300X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| OK | 6147210001 | Other | PTAN |
| 9060050 | Other | AETNA PIN | |
| 1618242 | Other | COVENTRY HEALTH CARE PROVIDER ID # | |
| 37D1067992 | Other | CLIA # FOR CROUCH FAMILY MEDICINE LAB (CLIA-WAIVED LAB) | |
| OK | 200116520A | Other | MEDICAID # FOR JASON CROUCH, D.O. |
| OK | 200116520A | Medicaid | |
| OKA104243 | Other | MEDICARE PTAN FOR JANENA MILBURN, APRN, CNP, FNP-C | |
| P00465778 | Other | RAILROAD MEDICARE PT. B PTAN | |
| 1215222666 | Other | NPI FOR JANENA MILBURN, APRN, CNP, FNP-C | |
| 1497890115 | Other | NPI FOR JASON CROUCH, D.O. (INDIVIDUAL) | |
| 4474235 | Other | CIGNA HEALTHCARE PROVIDER # | |
| 1609093228 | Other | NPI FOR CROUCH FAMILY MEDICINE (ORGANIZATION) | |
| 243722101 | Other | MEDICARE # FOR JASON CROUCH, D.O. | |
| 300522328 | Other | MEDICARE # FOR CROUCH FAMILY MEDICINE PC | |
| OK | 200116510A | Other | MEDICAID # FOR CROUCH FAMILY MEDICINE PC |
| OK | 200116510A | Medicaid | |
| 6147210001 | Other | DME PTAN FOR CROUCH FAMILY MEDICINE | |
| DG9878 | Other | RAILROAD MEDICARE PT. B GROUP NUMBER | |
| OK | 200116520A | Other | MEDICAID # FOR JASON CROUCH, D.O. |
| 243722101 | Other | MEDICARE # FOR JASON CROUCH, D.O. | |
| OK | 200116510A | Other | MEDICAID # FOR CROUCH FAMILY MEDICINE PC |
| 6147210001 | Medicare NSC | ||
| OK | 200116510A | Medicaid |
