Basic Information
| Provider Information | |||||||||
| NPI: | 1699762179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROTEAU | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | RUSSELL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 629D LOWTHER RD | ||||||||
| Address2: | |||||||||
| City: | LEWISBERRY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173399527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179382765 | ||||||||
| FaxNumber: | 7179323095 | ||||||||
| Practice Location | |||||||||
| Address1: | 4665 E TRINDLE RD | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170503640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179750445 | ||||||||
| FaxNumber: | 7177319165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD007267E | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.