Healthcare Provider Details

I. General information

NPI: 1720079841
Provider Name (Legal Business Name): MICHAEL EDWARD CRITCHLOW M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 N MAIN ST
SIKESTON MO
63801-5044
US

IV. Provider business mailing address

1012 N MAIN ST
SIKESTON MO
63801-5044
US

V. Phone/Fax

Practice location:
  • Phone: 573-471-0330
  • Fax: 573-472-2966
Mailing address:
  • Phone: 573-471-0330
  • Fax: 573-472-2966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number25720
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR8486
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: