Provider Demographics
NPI:1669590790
Name:CRYSTAL COMMUNITY E N T
Entity type:Organization
Organization Name:CRYSTAL COMMUNITY E N T
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SURRENCY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-795-0011
Mailing Address - Street 1:790 SE 5TH TER
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-4852
Mailing Address - Country:US
Mailing Address - Phone:352-795-0011
Mailing Address - Fax:352-795-9481
Practice Address - Street 1:790 SE 5TH TER
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4852
Practice Address - Country:US
Practice Address - Phone:352-795-0011
Practice Address - Fax:352-795-9481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5716207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80221OtherBCBS OF FLORIDA
FLDA5520OtherRAILROAD MCR GROUP#
FL1409549OtherUNITED MINE WORKERS
FLP00062969OtherRAILROAD MEDICARE
FL200691OtherAVMED
FL061333900Medicaid
FLB53251Medicare UPIN
FLK5054AMedicare PIN