Healthcare Provider Details

I. General information

NPI: 1861569261
Provider Name (Legal Business Name): MAX JAY CROUCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 S. PROFESSIONAL WAY
PAYSON UT
84651
US

IV. Provider business mailing address

1055 N 500 W
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-465-4896
  • Fax: 801-465-3267
Mailing address:
  • Phone: 801-465-4896
  • Fax: 801-465-3267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number181049-1205
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier181049-1205
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerSTATE LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: