1578732137 NPI number — CRESTWOOD MEDICAL GROUP INC

Table of content: (NPI 1578732137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578732137 NPI number — CRESTWOOD MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTWOOD MEDICAL GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578732137
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
47 CRESTWOOD RD
Provider Second Line Business Mailing Address:
STE #2 CRESTWOOD MEDICAL GROUP
Provider Business Mailing Address City Name:
KAYSVILLE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84037-1445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-546-1273
Provider Business Mailing Address Fax Number:
801-546-1631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47 CRESTWOOD RD
Provider Second Line Business Practice Location Address:
STE #2
Provider Business Practice Location Address City Name:
KAYSVILLE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84037-1445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-546-1273
Provider Business Practice Location Address Fax Number:
801-546-1631
Provider Enumeration Date:
02/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
801-546-1273

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  161981-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 248783020008 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com