Basic Information
| Provider Information | |||||||||
| NPI: | 1619938289 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRUTCHIK | ||||||||
| FirstName: | ALLAN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 15TH ST STE BI1056 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064465941 | ||||||||
| FaxNumber: | 7067219286 | ||||||||
| Practice Location | |||||||||
| Address1: | 6619 N WICKHAM RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212599500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 07/05/2018 | ||||||||
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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 | 207R00000X | ME131606 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RX0202X | MA34594 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | 080751 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 2947005 | 05 | NJ | MEDICAID |