Provider Demographics
NPI:1124150016
Name:CRUTCHER, SAMUEL JOHN (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JOHN
Last Name:CRUTCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 W. BADDOUR PARKWAY
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2513
Mailing Address - Country:US
Mailing Address - Phone:615-444-6203
Mailing Address - Fax:615-444-6252
Practice Address - Street 1:1407 W BADDOUR PKWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2513
Practice Address - Country:US
Practice Address - Phone:615-444-6203
Practice Address - Fax:615-444-6252
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29024207Q00000X
TN45549207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNMD45549OtherLICENSE
SC29024OtherLICENSE
SC290241Medicaid
TN3035474OtherUHC
TN11970229OtherCAQH
TN1522977Medicaid
TN4272184OtherBCBS
TN7919136OtherCIGNA
TN7919136OtherCIGNA
TN3035474OtherUHC
SCAA38962353Medicare PIN