Healthcare Provider Details

I. General information

NPI: 1598723959
Provider Name (Legal Business Name): JONATHAN SLADE CROWDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3203 MIDDLE ROAD
COLUMBUS IN
47203
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-373-2700
  • Fax: 812-373-2710
Mailing address:
  • Phone: 812-375-3000
  • Fax: 812-375-3477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01057432A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: