Provider Demographics
NPI:1548240054
Name:CRIST, MICHAEL R (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:CRIST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 FAIRLANE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628-2318
Mailing Address - Country:US
Mailing Address - Phone:660-258-3397
Mailing Address - Fax:660-258-3945
Practice Address - Street 1:814 FAIRLANE DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-2318
Practice Address - Country:US
Practice Address - Phone:660-258-3397
Practice Address - Fax:660-258-3945
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4A27207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO111986OtherBLUE CROSS BLUE SHIELD MO
MO241186600Medicaid
MO010066246OtherRAILROAD MEDICARE
MO108161OtherHEALTHLINK
MO1663OtherHEALTHCARE USA
MO108161OtherHEALTHLINK
MO000095597Medicare ID - Type Unspecified