MEDICARE: CROSSOVER HEALTH MEDICAL GROUP

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	174400000X	Specialist

General Provider Information

NPI Number	:	1861207961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSOVER HEALTH MEDICAL GROUP

Provider Business Mailing Address
First Line	:	726 13TH AVE E
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-3304
Country	:	US
Telephone Number	:	844-398-3640
Fax Number	:

Provider Business Practice Location Address
First Line	:	726 13TH AVE E
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-3304
Country	:	US
Telephone Number	:	844-398-3640
Fax Number	:

Authorized Official
Title or Position	:	SR. CREDENTIALING AND LICENSING
Name	:	JENETTE HUNTER
Credential	:	CPCS
Telephone Number	:	971-500-2661

Provider Enumeration Date	:	02/07/2025
Last Update Date	:	02/07/2025

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