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General NPI Number Information
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NPI Number | 1629321856
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Entity Type | Organization
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Legal Business Name | J L CROW PLASTIC SURGERY SERVICES
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Dates
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Enumeration Date | 10/25/2012
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Last Update Date | 10/25/2012
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Provider Practice Location Address
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Address Line | 1191 SOUTH COLUMBIA ROAD
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City | GRAND FORKS
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State | ND
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Zip | 58201-4033
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Country | US
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Telephone | 701-335-9717
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Fax | 701-746-1663
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Provider Business Mailing Address
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Address Line | 1191 SOUTH COLUMBIA ROAD
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City | GRAND FORKS
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State | ND
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Zip | 58201-4033
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Country | US
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Telephone | 701-335-9717
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Fax | 701-746-1663
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Authorized Official
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Title or Position | PRESIDENT / OWNER / PHYSICIAN
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Name | JUDSON L CROW
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Credential | MD
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Telephone | 218-779-9347
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 27269
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 4766
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License Number State | ND
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