Provider Demographics
NPI:1639353071
Name:K. THOMAS CROCKER, D.O., P.C.
Entity Type:Organization
Organization Name:K. THOMAS CROCKER, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:S
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-245-4513
Mailing Address - Street 1:4300 CASCADE RD SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3631
Mailing Address - Country:US
Mailing Address - Phone:616-245-4513
Mailing Address - Fax:616-245-4802
Practice Address - Street 1:4300 CASCADE RD SE
Practice Address - Street 2:SUITE 103
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3631
Practice Address - Country:US
Practice Address - Phone:616-245-4513
Practice Address - Fax:616-245-4802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007635207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1683584Medicaid
MI1683584Medicaid