Healthcare Provider Details

I. General information

NPI: 1467543140
Provider Name (Legal Business Name): MARC J. CRUPIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 CORDOVA STATION AVE
CORDOVA TN
38018-6318
US

IV. Provider business mailing address

P O BOX 4438
CORDOVA TN
38088-4438
US

V. Phone/Fax

Practice location:
  • Phone: 901-507-4400
  • Fax: 901-756-5836
Mailing address:
  • Phone: 901-507-4400
  • Fax: 901-756-5836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD0000015815
License Number StateTN

VII. Legacy identifiers

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

# 1
Identifier4064441
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerAETNA
# 2
Identifier3144579
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerBCBS OF TN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: