Provider Demographics
NPI:1669468930
Name:CRESCENT CITY INTERNAL MEDICINE
Entity Type:Organization
Organization Name:CRESCENT CITY INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLUNDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-465-8666
Mailing Address - Street 1:1771 NORTHCREST DR
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-8922
Mailing Address - Country:US
Mailing Address - Phone:707-465-8666
Mailing Address - Fax:707-465-8650
Practice Address - Street 1:1771 NORTHCREST DR
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8922
Practice Address - Country:US
Practice Address - Phone:707-465-8666
Practice Address - Fax:707-465-8650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0087830Medicaid
CAZZZ13827ZMedicare Oscar/Certification
ORR103270Medicare PIN