Provider Demographics
NPI:1003866104
Name:CRIST, GENE ALLEN (DO)
Entity type:Individual
Prefix:
First Name:GENE
Middle Name:ALLEN
Last Name:CRIST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:G ALLEN
Other - Middle Name:
Other - Last Name:CRIST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2201
Mailing Address - Country:US
Mailing Address - Phone:563-584-4100
Mailing Address - Fax:563-584-4110
Practice Address - Street 1:10988 BARTEL BLVD
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036-8222
Practice Address - Country:US
Practice Address - Phone:815-777-0900
Practice Address - Fax:815-777-0903
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-071169207Q00000X
IA03204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071169Medicaid
IL036071169Medicaid
IAL70644Medicare ID - Type Unspecified