1760931844 NPI number — CRYSTAL RUN HEALTHCARE PHYSICIANS LLP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760931844 NPI number — CRYSTAL RUN HEALTHCARE PHYSICIANS LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTAL RUN HEALTHCARE PHYSICIANS LLP
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:
1760931844
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 CRYSTAL RUN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10941-4028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-703-6999
Provider Business Mailing Address Fax Number:
845-703-6297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
855 STATE ROUTE 17M
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10950-1600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-703-6999
Provider Business Practice Location Address Fax Number:
845-703-6297
Provider Enumeration Date:
09/29/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SPENCER
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
845-703-6999

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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