1164489175 NPI number — CRESTHAVEN INTERNAL MEDICINE ASSOCIATES

Table of content: (NPI 1164489175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164489175 NPI number — CRESTHAVEN INTERNAL MEDICINE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTHAVEN INTERNAL MEDICINE ASSOCIATES
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:
1164489175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1000 DEPT 558
Provider Second Line Business Mailing Address:
CRESTHAVEN INTERNAL MEDICINE
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-821-8300
Provider Business Mailing Address Fax Number:
901-259-9793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6799 GREAT OAKS ROAD # 250
Provider Second Line Business Practice Location Address:
CRESTHAVEN INTERNAL MEDICINE
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-821-8300
Provider Business Practice Location Address Fax Number:
901-259-9793
Provider Enumeration Date:
04/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEATON
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
901-821-8300

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 19006 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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