Provider Demographics
NPI:1902992050
Name:CRANICK, SCOTT WESLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:WESLEY
Last Name:CRANICK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:800-457-5200
Mailing Address - Fax:
Practice Address - Street 1:201 S 14TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3631
Practice Address - Country:US
Practice Address - Phone:618-942-2171
Practice Address - Fax:618-351-4917
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002739207P00000X, 363A00000X
FLPA9103859363A00000X
NC0010-00923363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherMEDICARE OSCAR
IL3932056OtherBLUE SHIELD
FLAB913ZMedicare PIN
ORP00717182Medicare PIN
FLQ77317Medicare UPIN
IL3932056OtherBLUE SHIELD
IL214881043Medicare PIN