Provider Demographics
NPI:1336361351
Name:CROUCH, JEREMY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:MICHAEL
Last Name:CROUCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S DIXIE DR
Mailing Address - Street 2:STE 40
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-2657
Mailing Address - Country:US
Mailing Address - Phone:937-890-6644
Mailing Address - Fax:937-890-1726
Practice Address - Street 1:900 S DIXIE DR
Practice Address - Street 2:STE 40
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-2657
Practice Address - Country:US
Practice Address - Phone:937-890-6644
Practice Address - Fax:937-890-1726
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.095689207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3068013Medicaid
OH4293902Medicare PIN