Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 28795 | KY |
Y | 208D00000X | General Practice Physician | 28795 | KY |
NPI | 1003828633 |
---|---|
Provider Name | Dr. William D Crecelius |
First Address | Chicago, IL 60677-6351 |
Second Address | Louisville, KY 40203-3607 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2006 |
Last Update Date | 13/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000048676 | ANTHEM (01) | KY |
10523140 | PASSPORT (01) | KY |
200009610 | (05) | IN |
2433207000 | PASSPORT ADVANTAGE (01) | KY |
64287956 | (05) | KY |
F40220 | (02) | KY |