Provider Demographics
NPI:1790886885
Name:CRESCENT INTERNAL MEDICINE GROUP, LLC
Entity Type:Organization
Organization Name:CRESCENT INTERNAL MEDICINE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:KRUPP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-783-0800
Mailing Address - Street 1:29 THE CRESCENT
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2636
Mailing Address - Country:US
Mailing Address - Phone:973-783-0800
Mailing Address - Fax:973-744-1274
Practice Address - Street 1:29 THE CRESCENT
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2636
Practice Address - Country:US
Practice Address - Phone:973-783-0800
Practice Address - Fax:973-744-1274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB071292207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00059104OtherRAILROAD MEDICARE
NJP00059104OtherRAILROAD MEDICARE
NJP00059104OtherRAILROAD MEDICARE
NJ073514Medicare PIN