Provider Demographics
NPI:1619925880
Name:CROUCH, DONALD SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:SCOTT
Last Name:CROUCH
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 1:1414 CROSS ST STE 330
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2988
Mailing Address - Country:US
Mailing Address - Phone:618-277-7400
Mailing Address - Fax:618-277-7422
Practice Address - Street 1:1414 CROSS ST STE 330
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:618-277-7400
Practice Address - Fax:618-277-7422
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106785208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106785Medicaid
IL211003Medicare ID - Type Unspecified
ILK14796Medicare ID - Type Unspecified