Provider Demographics
NPI:1164489175
Name:CRESTHAVEN INTERNAL MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:CRESTHAVEN INTERNAL MEDICINE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-821-8300
Mailing Address - Street 1:PO BOX 1000 DEPT 558
Mailing Address - Street 2:CRESTHAVEN INTERNAL MEDICINE
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148
Mailing Address - Country:US
Mailing Address - Phone:901-821-8300
Mailing Address - Fax:901-259-9793
Practice Address - Street 1:6799 GREAT OAKS ROAD # 250
Practice Address - Street 2:CRESTHAVEN INTERNAL MEDICINE
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-821-8300
Practice Address - Fax:901-259-9793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN19006OtherBCBS
TN3382620Medicare ID - Type Unspecified