Provider Demographics
NPI:1881424885
Name:CRESCENT INTEGRATIVE MEDICAL PLLC
Entity type:Organization
Organization Name:CRESCENT INTEGRATIVE MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:KHAWAJA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-671-7770
Mailing Address - Street 1:235 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2034
Mailing Address - Country:US
Mailing Address - Phone:516-671-7770
Mailing Address - Fax:
Practice Address - Street 1:235 FOREST AVE
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2034
Practice Address - Country:US
Practice Address - Phone:516-671-7770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty