Basic Information
| Provider Information | |||||||||
| NPI: | 1760564710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CREW | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 622 W 168TH ST | ||||||||
| Address2: | PH 4-124 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123053273 | ||||||||
| FaxNumber: | 2123056692 | ||||||||
| Practice Location | |||||||||
| Address1: | 622 W 168TH ST | ||||||||
| Address2: | PH 4-124 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123053273 | ||||||||
| FaxNumber: | 2123056692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 219461 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 219461 | 01 | NY | STATE LICENSE | OTHER |