Provider Demographics
NPI:1891779906
Name:CROOM, ANGELA J (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:J
Last Name:CROOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10711 W 145TH TER
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66221-2553
Mailing Address - Country:US
Mailing Address - Phone:913-499-6542
Mailing Address - Fax:
Practice Address - Street 1:5808 W 110TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-2504
Practice Address - Country:US
Practice Address - Phone:913-696-8746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160504208000000X
KS0431871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201431202Medicaid
KS200388210AMedicaid
MA3197263Medicaid
MA3197263Medicaid
MACR A29990Medicare ID - Type Unspecified