Healthcare Provider Details

I. General information

NPI: 1063411908
Provider Name (Legal Business Name): KESTER I.H. CROSSE II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date: 04/06/2006
Reactivation Date: 04/06/2006

III. Provider practice location address

10710 CHARTER DR SUITE 110
COLUMBIA MD
21044-3258
US

IV. Provider business mailing address

10710 CHARTER DR SUITE 110
COLUMBIA MD
21044-3258
US

V. Phone/Fax

Practice location:
  • Phone: 410-992-9797
  • Fax: 410-730-0942
Mailing address:
  • Phone: 410-992-9797
  • Fax: 410-730-0942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD0059817
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: