Healthcare Provider Details

I. General information

NPI: 1710060876
Provider Name (Legal Business Name): CHARLES CRASE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 METKER TRL
STANFORD KY
40484-1065
US

IV. Provider business mailing address

PO BOX 990
DANVILLE KY
40423-0990
US

V. Phone/Fax

Practice location:
  • Phone: 859-239-2379
  • Fax: 859-239-6898
Mailing address:
  • Phone: 859-239-2379
  • Fax: 859-239-6898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17572
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: