=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003845405
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN A CROUCH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2006
-----------------------------------------------------
Last Update Date | 09/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 SAINT MARYS MEDICAL PLZ SUITE 203
-----------------------------------------------------
City | JEFFERSON CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65101-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-761-7243
-----------------------------------------------------
Fax | 573-761-7196
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 SAINT MARYS MEDICAL PLZ SUITE 203
-----------------------------------------------------
City | JEFFERSON CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65101-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-761-7243
-----------------------------------------------------
Fax | 573-761-7196
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | 34746
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------