=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104614361
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN A. CROSSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2025
-----------------------------------------------------
Last Update Date | 04/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 226 MOUNTAIN RD
-----------------------------------------------------
City | SUFFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06078-2082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-901-2097
-----------------------------------------------------
Fax | 860-899-1050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 226 MOUNTAIN RD
-----------------------------------------------------
City | SUFFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06078-2082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-965-5523
-----------------------------------------------------
Fax | 860-899-1050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 004657
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------