Healthcare Provider Details

I. General information

NPI: 1578680914
Provider Name (Legal Business Name): KEVIN EDMOND CRUTCHFIELD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 04/24/2022
Certification Date: 04/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 ESSEX ST
HACKENSACK NJ
07601-8550
US

IV. Provider business mailing address

12513 BRACKEN HILL LN
POTOMAC MD
20854-1116
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-8100
  • Fax: 551-996-4140
Mailing address:
  • Phone: 410-601-9515
  • Fax: 410-601-8905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number25MA08248800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0101044892
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101044892
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number25MA08248800
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: