Provider Demographics
NPI:1356301980
Name:CRISALLI, ROBERT JAMES (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
Last Name:CRISALLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MORRIS STREET
Mailing Address - Street 2:SUITE 357
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1326
Mailing Address - Country:US
Mailing Address - Phone:304-388-3574
Mailing Address - Fax:304-388-6481
Practice Address - Street 1:501 MORRIS ST
Practice Address - Street 2:GENERAL ADMINISTRATION
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1326
Practice Address - Country:US
Practice Address - Phone:304-388-6203
Practice Address - Fax:304-388-6481
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11220207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0082953000Medicaid
P00955646Medicare PIN
WV0082953000Medicaid
CR0458473Medicare PIN
WV0458472Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER