Provider Demographics
NPI:1104812742
Name:CRESCENT PRIMARY CARE PHYSICIANS PC
Entity type:Organization
Organization Name:CRESCENT PRIMARY CARE PHYSICIANS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:FOWZIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-922-1400
Mailing Address - Street 1:2132 DEEP WATER LN
Mailing Address - Street 2:STE 228
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8498
Mailing Address - Country:US
Mailing Address - Phone:630-922-1400
Mailing Address - Fax:630-904-7378
Practice Address - Street 1:2132 DEEP WATER LN
Practice Address - Street 2:STE 228
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-8498
Practice Address - Country:US
Practice Address - Phone:630-922-1400
Practice Address - Fax:630-904-7378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
584270Medicare ID - Type Unspecified