MEDICARE: PHILLIP M CROAK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1023513165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP M CROAK

Provider Business Mailing Address
First Line	:	5025 E PACIFIC COAST HWY APT P231
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804-3239
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5025 E PACIFIC COAST HWY APT P231
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804-3239
Country	:	US
Telephone Number	:	253-579-3811
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2018
Last Update Date	:	03/29/2018

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Directions to “ PHILLIP M CROAK ” Practice Location

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