Provider Demographics
NPI:1376631762
Name:CRYSTAL SPRINGS SURGICAL ASSOCIATES, A MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CRYSTAL SPRINGS SURGICAL ASSOCIATES, A MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:FENG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-685-2959
Mailing Address - Street 1:101 S SAN MATEO DR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3819
Mailing Address - Country:US
Mailing Address - Phone:650-685-2959
Mailing Address - Fax:
Practice Address - Street 1:101 S SAN MATEO DR
Practice Address - Street 2:SUITE 302
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3819
Practice Address - Country:US
Practice Address - Phone:650-685-2959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG079786208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG23531Medicare UPIN
CA00G797860Medicare ID - Type Unspecified