Provider Demographics
NPI:1841397460
Name:CROUSE, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CROUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 PIERCE ST
Mailing Address - Street 2:SUITE 217
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5149
Mailing Address - Country:US
Mailing Address - Phone:570-714-8614
Mailing Address - Fax:570-714-8616
Practice Address - Street 1:250 PIERCE ST
Practice Address - Street 2:SUITE 217
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5149
Practice Address - Country:US
Practice Address - Phone:570-714-8614
Practice Address - Fax:570-714-8616
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD044097L207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012448150003Medicaid
PA0012448150003Medicaid
PAE85354Medicare UPIN