Provider Demographics
NPI:1386990638
Name:CROUSE MEDICAL PRACTICE PLLC
Entity type:Organization
Organization Name:CROUSE MEDICAL PRACTICE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE SHAREHOLDER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KRONENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-470-7825
Mailing Address - Street 1:PO BOX 91004
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14692-9104
Mailing Address - Country:US
Mailing Address - Phone:315-446-3904
Mailing Address - Fax:315-552-6590
Practice Address - Street 1:5823 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-3081
Practice Address - Country:US
Practice Address - Phone:315-474-6824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROUSE MEDICAL PRACTICE PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty