Provider Demographics
NPI:1598966343
Name:CRESTVIEW HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:CRESTVIEW HOSPITAL CORPORATION
Other - Org Name:CRESTVIEW SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIR ONBOARDING & PROV ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:PO BOX 198002
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8002
Mailing Address - Country:US
Mailing Address - Phone:850-689-8100
Mailing Address - Fax:
Practice Address - Street 1:400 REDSTONE AVE W
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-8467
Practice Address - Country:US
Practice Address - Phone:850-689-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4298261Q00000X, 261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100122Medicare ID - Type Unspecified