1508506098 NPI number — KEIRSYN MCDANIEL CRISS

Table of content: KEIRSYN MCDANIEL CRISS (NPI 1508506098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508506098 NPI number — KEIRSYN MCDANIEL CRISS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRISS
Provider First Name:
KEIRSYN
Provider Middle Name:
MCDANIEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCDANIEL
Provider Other First Name:
KEIRSYN
Provider Other Middle Name:
LEANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508506098
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ATRIUM HEALTH WAKE FOREST BAPTIST MEDICAL CENTER
Provider Second Line Business Mailing Address:
MEDICAL CENTER BOULEVARD
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27157-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ATRIUM HEALTH WAKE FOREST BAPTIST MEDICAL CENTER
Provider Second Line Business Practice Location Address:
MEDICAL CENTER BOULEVARD
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27157-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-716-6410
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)