Provider Demographics
NPI:1992733091
Name:CROSSMAN, KEVIN M (PT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:CROSSMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3875 NEW HOLLAND ST
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 5TH ST NW
Practice Address - Street 2:SUITE 404
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5219
Practice Address - Country:US
Practice Address - Phone:616-356-5000
Practice Address - Fax:616-356-5001
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003422225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650E410320OtherBCBSM
MI650G011770OtherBCBS
MI1992733091OtherNPI
MI5501003422OtherSTATE OF MICHIGAN
MI236850OtherMDCR FACILITY NUMBER
MI650G011770OtherBCBS
MI0P38990002Medicare PIN
MIP04810002Medicare ID - Type UnspecifiedWPS MEDICARE
MI5501003422OtherSTATE OF MICHIGAN