Healthcare Provider Details

I. General information

NPI: 1265496152
Provider Name (Legal Business Name): JERRY DEAN CRUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 02/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NW 11TH ST SUITE E19
HERMISTON OR
97838-8605
US

IV. Provider business mailing address

600 NW 11TH ST SUITE E19
HERMISTON OR
97838-8605
US

V. Phone/Fax

Practice location:
  • Phone: 541-289-7171
  • Fax: 541-289-7172
Mailing address:
  • Phone: 541-289-7171
  • Fax: 541-289-7172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberG87585
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: