=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316228489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROWN OB/GYN PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2011
-----------------------------------------------------
Last Update Date | 09/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2056 WOODLANE DR SUITE 100
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125-2917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-209-0084
-----------------------------------------------------
Fax | 651-209-0388
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2056 WOODLANE DR SUITE 100
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125-2917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-209-0084
-----------------------------------------------------
Fax | 651-209-0388
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / OWNER
-----------------------------------------------------
Name | JORY M BURROUGHS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 651-209-0084
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 1817
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------