Healthcare Provider Details

I. General information

NPI: 1629117700
Provider Name (Legal Business Name): GREGORY H CROLL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 E BDWY STE 214
COLUMBIA MO
65201
US

IV. Provider business mailing address

703 W ROLLINS RD
COLUMBIA MO
65203-2847
US

V. Phone/Fax

Practice location:
  • Phone: 573-817-1800
  • Fax: 573-817-1900
Mailing address:
  • Phone: 573-817-1800
  • Fax: 573-817-1900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number36468
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: