Provider Demographics
NPI:1538229604
Name:DR WILBOURNE R CROUCH, M.D.
Entity type:Organization
Organization Name:DR WILBOURNE R CROUCH, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:WILBOURNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CROUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-773-5429
Mailing Address - Street 1:301 PINE ST NW
Mailing Address - Street 2:SUITE B
Mailing Address - City:HARTSELLE
Mailing Address - State:AL
Mailing Address - Zip Code:35640-2338
Mailing Address - Country:US
Mailing Address - Phone:256-773-5429
Mailing Address - Fax:256-773-4888
Practice Address - Street 1:301 PINE ST NW
Practice Address - Street 2:SUITE B
Practice Address - City:HARTSELLE
Practice Address - State:AL
Practice Address - Zip Code:35640-2338
Practice Address - Country:US
Practice Address - Phone:256-773-5429
Practice Address - Fax:256-773-4888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALN05434207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC70034Medicare UPIN
AL000001530Medicare ID - Type Unspecified