Provider Demographics
NPI:1740546621
Name:CRYSTAL MEDICAL GROUP PA
Entity type:Organization
Organization Name:CRYSTAL MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIRMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-674-4542
Mailing Address - Street 1:5 BROWN CT
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-1521
Mailing Address - Country:US
Mailing Address - Phone:973-674-4542
Mailing Address - Fax:
Practice Address - Street 1:310 CENTRAL AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2835
Practice Address - Country:US
Practice Address - Phone:973-674-4542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE84822Medicare UPIN