=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770772931
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEROME C CREPEAU M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2007
-----------------------------------------------------
Last Update Date | 10/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 BREWSTER ST
-----------------------------------------------------
City | PROVINCETOWN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02657-1631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-487-2382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 BREWSTER ST
-----------------------------------------------------
City | PROVINCETOWN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02657-1631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-487-2382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 55114
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------