Provider Demographics
NPI:1679977128
Name:CRISWELL, MICHAEL E (CNS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:CRISWELL
Suffix:
Gender:M
Credentials:CNS
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 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:1500 SALEM ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2164
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28074750A364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000905209OtherANTHEM PROVIDER NUMBER
IN201262580Medicaid
INP01550358Medicare PIN
IN815500081Medicare PIN