Provider Demographics
NPI: | 1952376410 |
---|---|
Name: | CRYSTAL RUN HEALTHCARE PHYSICIANS LLP |
Entity Type: | Organization |
Organization Name: | CRYSTAL RUN HEALTHCARE PHYSICIANS LLP |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CHIEF MEDICAL OFFICER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | GREGORY |
Authorized Official - Middle Name: | A |
Authorized Official - Last Name: | SPENCER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 845-703-6999 |
Mailing Address - Street 1: | 155 CRYSTAL RUN RD |
Mailing Address - Street 2: | |
Mailing Address - City: | MIDDLETOWN |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 10941-4028 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 845-703-6999 |
Mailing Address - Fax: | 845-703-6297 |
Practice Address - Street 1: | 155 CRYSTAL RUN RD |
Practice Address - Street 2: | |
Practice Address - City: | MIDDLETOWN |
Practice Address - State: | NY |
Practice Address - Zip Code: | 10941-4028 |
Practice Address - Country: | US |
Practice Address - Phone: | 845-703-6999 |
Practice Address - Fax: | 845-703-6297 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-02-20 |
Last Update Date: | 2023-10-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 207K00000X, 207P00000X, 207Q00000X, 207R00000X, 207RC0000X, 207RC0001X, 207RC0200X, 207RE0101X, 207RG0100X, 207RG0300X, 207RH0003X, 207RI0011X, 207RI0200X, 207RM1200X, 208D00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RC0001X | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | Group - Multi-Specialty |
No | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RG0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | Group - Multi-Specialty |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 207RI0011X | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | Group - Multi-Specialty |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207RM1200X | Allopathic & Osteopathic Physicians | Internal Medicine | Magnetic Resonance Imaging (MRI) | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 02409709 | Medicaid | |
NY | 02409709 | Medicaid | |
NY | W4T771 | Medicare PIN |