MEDICARE: DR WILBOURNE R CROUCH, M.D.

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	207Q00000X	Family Medicine Physician	N05434	AL

General Provider Information

NPI Number	:	1538229604
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR WILBOURNE R CROUCH, M.D.

Provider Business Mailing Address
First Line	:	301 PINE ST NW
Second Line	:	SUITE B
City	:	HARTSELLE
State	:	AL
Zip	:	35640-2338
Country	:	US
Telephone Number	:	256-773-5429
Fax Number	:	256-773-4888

Provider Business Practice Location Address
First Line	:	301 PINE ST NW
Second Line	:	SUITE B
City	:	HARTSELLE
State	:	AL
Zip	:	35640-2338
Country	:	US
Telephone Number	:	256-773-5429
Fax Number	:	256-773-4888

Authorized Official
Title or Position	:	MD
Name	:	DR. WILBOURNE R CROUCH
Credential	:	MD
Telephone Number	:	256-773-5429

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	04/07/2010

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