Provider Demographics
NPI:1790049468
Name:CROW CREEK THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:CROW CREEK THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEARHEART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-813-4210
Mailing Address - Street 1:3750 PRIORITY WAY SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-3831
Mailing Address - Country:US
Mailing Address - Phone:888-420-2337
Mailing Address - Fax:866-566-4257
Practice Address - Street 1:23939 RESEARCH DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-2630
Practice Address - Country:US
Practice Address - Phone:313-634-4856
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM261929332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1790049468Medicaid
MI1790049468Medicaid