Provider Demographics
NPI:1891110540
Name:CROSEN MEDICAL, LLC
Entity Type:Organization
Organization Name:CROSEN MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/ AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:S
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:AO
Authorized Official - Phone:256-770-7197
Mailing Address - Street 1:1011 LEIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-5701
Mailing Address - Country:US
Mailing Address - Phone:256-770-7197
Mailing Address - Fax:256-405-4439
Practice Address - Street 1:1011 LEIGHTON AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-5701
Practice Address - Country:US
Practice Address - Phone:256-770-7197
Practice Address - Fax:256-405-4439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19946174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051554151Medicaid
AL1700811072Medicaid