Healthcare Provider Details

I. General information

NPI: 1093063596
Provider Name (Legal Business Name): W.MICHAEL CROSBY M.D. PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 CRESSETT ST
GILLETTE WY
82716-3339
US

IV. Provider business mailing address

1601 E 17TH ST
IDAHO FALLS ID
83404-6313
US

V. Phone/Fax

Practice location:
  • Phone: 208-525-2090
  • Fax: 208-526-2662
Mailing address:
  • Phone: 208-525-2090
  • Fax: 208-525-2662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4201A
License Number StateWY

VIII. Authorized Official

Name: MR. MICAHEL CROSBY
Title or Position: OWNER
Credential: M.D.
Phone: 208-525-2090