Provider Demographics
NPI:1720079841
Name:CRITCHLOW, MICHAEL EDWARD (M D)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:CRITCHLOW
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5044
Mailing Address - Country:US
Mailing Address - Phone:573-471-0330
Mailing Address - Fax:573-472-2966
Practice Address - Street 1:1012 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5044
Practice Address - Country:US
Practice Address - Phone:573-471-0330
Practice Address - Fax:573-472-2966
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO25720207K00000X
MOR8486207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200384220Medicaid
MO000004173Medicare PIN
A13334Medicare UPIN