Provider Demographics
NPI:1578732137
Name:CRESTWOOD MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CRESTWOOD 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:B
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-546-1273
Mailing Address - Street 1:47 CRESTWOOD RD
Mailing Address - Street 2:STE #2 CRESTWOOD MEDICAL GROUP
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-1445
Mailing Address - Country:US
Mailing Address - Phone:801-546-1273
Mailing Address - Fax:801-546-1631
Practice Address - Street 1:47 CRESTWOOD RD
Practice Address - Street 2:STE #2
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-1445
Practice Address - Country:US
Practice Address - Phone:801-546-1273
Practice Address - Fax:801-546-1631
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRESTWOOD MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT161981-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT248783020008Medicaid
UTD20465Medicare UPIN