Provider Demographics
NPI:1629321856
Name:J L CROW PLASTIC SURGERY SERVICES
Entity Type:Organization
Organization Name:J L CROW PLASTIC SURGERY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER / PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JUDSON
Authorized Official - Middle Name:L
Authorized Official - Last Name:CROW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-779-9347
Mailing Address - Street 1:1191 SOUTH COLUMBIA ROAD
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4033
Mailing Address - Country:US
Mailing Address - Phone:701-335-9717
Mailing Address - Fax:701-746-1663
Practice Address - Street 1:1191 SOUTH COLUMBIA ROAD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4033
Practice Address - Country:US
Practice Address - Phone:701-335-9717
Practice Address - Fax:701-746-1663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4766208200000X
MN27269208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14106Medicaid
ND14106Medicaid