Provider Demographics
NPI:1164604187
Name:KRYSTAL MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:KRYSTAL MEDICAL ASSOCIATES LLC
Other - Org Name:KRYSTAL MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NWAEHIHIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:ONYEAGHALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-486-0100
Mailing Address - Street 1:12150 ANNAPOLIS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9183
Mailing Address - Country:US
Mailing Address - Phone:301-464-7601
Mailing Address - Fax:
Practice Address - Street 1:12150 ANNAPOLIS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9183
Practice Address - Country:US
Practice Address - Phone:301-464-7601
Practice Address - Fax:866-885-9817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053461261QM1300X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402647100Medicaid
VA010012902Medicaid
DC034934800Medicaid