Basic Information
| Provider Information | |||||||||
| NPI: | 1376798918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUM | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407430936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063307818 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 4305 NEW SHEPHERDSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BARDSTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023505032 | ||||||||
| FaxNumber: | 5023505022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2008 | ||||||||
| LastUpdateDate: | 08/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN 274000 | OH | N | Nursing Service Providers | Registered Nurse | 367500000X | 3007686 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 7100232210-KOHMG | 05 | KY | MEDICAID | P01977534-KOHMG | 01 | KY | RR MEDICARE | OTHER | 300011007A-KOHMG | 05 | IN | MEDICAID | K074154-KOHMG | 01 | KY | KY MEDICARE | OTHER |