Provider Demographics
NPI:1689623092
Name:KROUSE, MICHAEL D (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:KROUSE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W. OAK ST
Mailing Address - Street 2:
Mailing Address - City:PAYNE
Mailing Address - State:OH
Mailing Address - Zip Code:45880-9700
Mailing Address - Country:US
Mailing Address - Phone:419-263-1393
Mailing Address - Fax:419-263-1393
Practice Address - Street 1:110 WEST OAK STREET
Practice Address - Street 2:
Practice Address - City:PAYNE
Practice Address - State:OH
Practice Address - Zip Code:45880-1057
Practice Address - Country:US
Practice Address - Phone:419-263-1393
Practice Address - Fax:419-263-1393
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002265A111N00000X
OH2973111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2768223Medicaid
OH4010121Medicare PIN