Provider Demographics
NPI:1104142355
Name:MCCROHAN, NYDIA (MD)
Entity type:Individual
Prefix:
First Name:NYDIA
Middle Name:
Last Name:MCCROHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10628 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8407
Practice Address - Country:US
Practice Address - Phone:704-512-5363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-00830207RH0002X, 2084H0002X
IL0360887042084N0008X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084H0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyHospice and Palliative Medicine
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2732Medicaid
NC1104142355Medicaid
ILF95469Medicare UPIN
SCNC2732Medicaid
IL359000Medicare PIN