Provider Demographics
NPI:1538348032
Name:JOHN R CREW MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JOHN R CREW MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CREW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-994-2700
Mailing Address - Street 1:PO BOX 2299
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94017-2299
Mailing Address - Country:US
Mailing Address - Phone:650-994-2700
Mailing Address - Fax:650-755-0410
Practice Address - Street 1:1850 SULLIVAN AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2221
Practice Address - Country:US
Practice Address - Phone:650-994-2700
Practice Address - Fax:650-755-0410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC20787174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C207870Medicaid
CA1215042163OtherNPI SOLO
CA00C207870Medicaid
CAZZZ05680ZMedicare PIN