Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 4004 | AL |
Y | 213EG0000X | General Practice | 4004 | AL |
NPI | 1003830134 |
---|---|
Provider Name | Dr. Benjamin Alan Crunk |
First Address | Montevallo, AL 35115-3847 |
Second Address | Montevallo, AL 35115-3847 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2006 |
Last Update Date | 12/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
#05152 | (02) | AL |
510-03995 | BC/BS OF AL PROVIDER # (01) | AL |