Provider Demographics
NPI:1033166178
Name:CRESTANI FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:CRESTANI FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PANDA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-534-1323
Mailing Address - Street 1:PO BOX 2586
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-2586
Mailing Address - Country:US
Mailing Address - Phone:256-534-1323
Mailing Address - Fax:256-534-1780
Practice Address - Street 1:2745 BOB WALLACE AVE SW
Practice Address - Street 2:SUITE D
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805-4158
Practice Address - Country:US
Practice Address - Phone:256-534-1323
Practice Address - Fax:256-534-1780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALK784Medicare ID - Type UnspecifiedGROUP NUMBER
ALH48252Medicare UPIN