Healthcare Provider Details

I. General information

NPI: 1386990638
Provider Name (Legal Business Name): CROUSE MEDICAL PRACTICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5823 WIDEWATERS PKWY
EAST SYRACUSE NY
13057-3081
US

IV. Provider business mailing address

PO BOX 91004
ROCHESTER NY
14692-9104
US

V. Phone/Fax

Practice location:
  • Phone: 315-474-6824
  • Fax:
Mailing address:
  • Phone: 315-446-3904
  • Fax: 315-552-6590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: PAUL KRONENBERG
Title or Position: SOLE SHAREHOLDER
Credential: MD
Phone: 315-470-7825