Provider Demographics
NPI:1346506979
Name:CRISFIELD CLINIC LLC
Entity Type:Organization
Organization Name:CRISFIELD CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:COLLEEN
Authorized Official - Last Name:PALAKANIS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:443-493-0062
Mailing Address - Street 1:4384 CRISFIELD HWY
Mailing Address - Street 2:
Mailing Address - City:CRISFIELD
Mailing Address - State:MD
Mailing Address - Zip Code:21817-2550
Mailing Address - Country:US
Mailing Address - Phone:410-968-1800
Mailing Address - Fax:
Practice Address - Street 1:4384 CRISFIELD HWY
Practice Address - Street 2:
Practice Address - City:CRISFIELD
Practice Address - State:MD
Practice Address - Zip Code:21817-2550
Practice Address - Country:US
Practice Address - Phone:410-968-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR105366363LF0000X
MDR091871363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS04020Medicare UPIN