1164604187 NPI number — KRYSTAL MEDICAL ASSOCIATES LLC

Table of content: (NPI 1164604187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164604187 NPI number — KRYSTAL MEDICAL ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KRYSTAL MEDICAL ASSOCIATES LLC
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:
6
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:
1164604187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12150 ANNAPOLIS RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GLENN DALE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20769-9183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-464-7601
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12150 ANNAPOLIS RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GLENN DALE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20769-9183
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-464-7601
Provider Business Practice Location Address Fax Number:
866-885-9817
Provider Enumeration Date:
11/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ONYEAGHALA
Authorized Official First Name:
NWAEHIHIE
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
301-486-0100

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  D0053461 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , with the licence number: D0053461 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 402647100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010012902 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 034934800 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".




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