Healthcare Provider Details

I. General information

NPI: 1114244613
Provider Name (Legal Business Name): MARY CHUMBLEY CROW M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 EAST BERT KOUNS SUITE 400
SHREVEPORT LA
71115-5741
US

IV. Provider business mailing address

1811 E BERT KOUNS INDUSTRIAL LOOP SUITE 400
SHREVEPORT LA
71105-5740
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-3810
  • Fax: 318-212-3815
Mailing address:
  • Phone: 318-212-3810
  • Fax: 318-212-3815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.204709
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: