Provider Demographics
NPI:1306993894
Name:CRUM, PHILIP JAY (AT,C)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:JAY
Last Name:CRUM
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71843 EAST POND CREEK
Mailing Address - Street 2:
Mailing Address - City:BRUCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48065
Mailing Address - Country:US
Mailing Address - Phone:586-331-7009
Mailing Address - Fax:
Practice Address - Street 1:6500 25 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-1703
Practice Address - Country:US
Practice Address - Phone:586-797-1300
Practice Address - Fax:586-797-1301
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL4889352255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program