Provider Demographics
NPI:1316228489
Name:CROWN OB/GYN PA
Entity type:Organization
Organization Name:CROWN OB/GYN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURROUGHS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-209-0084
Mailing Address - Street 1:2056 WOODLANE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2917
Mailing Address - Country:US
Mailing Address - Phone:651-209-0084
Mailing Address - Fax:651-209-0388
Practice Address - Street 1:2056 WOODLANE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2917
Practice Address - Country:US
Practice Address - Phone:651-209-0084
Practice Address - Fax:651-209-0388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-02
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1817207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1316228489Medicaid
MNC05980Medicare PIN