Provider Demographics
NPI:1669076527
Name:CRUSE, GREG
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:CRUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 E PARKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-1935
Mailing Address - Country:US
Mailing Address - Phone:937-726-7529
Mailing Address - Fax:
Practice Address - Street 1:717 E PARKWOOD ST
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-1935
Practice Address - Country:US
Practice Address - Phone:937-726-7529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH109457171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor