MEDICARE: JACK CRAWFORD CSA, CST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZC0007X	Surgical Assistant	10-227	TN

General Provider Information

NPI Number	:	1013345453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK CRAWFORD CSA, CST

Provider Business Mailing Address
First Line	:	3121 BRIMSTEAD DR
Second Line	:
City	:	FRANKLIN
State	:	TN
Zip	:	37064-6225
Country	:	US
Telephone Number	:	615-775-8953
Fax Number	:

Provider Business Practice Location Address
First Line	:	3121 BRIMSTEAD DR
Second Line	:
City	:	FRANKLIN
State	:	TN
Zip	:	37064-6225
Country	:	US
Telephone Number	:	615-775-8953
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2013
Last Update Date	:	10/22/2013

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