Healthcare Provider Details

I. General information

NPI: 1538500152
Provider Name (Legal Business Name): CROUSE MEDICAL PRACTICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 IRVING AVE SUITE 418
SYRACUSE NY
13210-1756
US

IV. Provider business mailing address

475 IRVING AVE SUITE 418
SYRACUSE NY
13210-1756
US

V. Phone/Fax

Practice location:
  • Phone: 315-475-3999
  • Fax:
Mailing address:
  • Phone: 315-475-3999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

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