Basic Information
| Provider Information | |||||||||
| NPI: | 1003897372 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CREST RADIOLOGICAL ASSOCIATES INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 W CHEW ST | ||||||||
| Address2: | PHYSICIAN ACCOUNTS | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181023406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107765100 | ||||||||
| FaxNumber: | 6106633113 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 W CHEW ST | ||||||||
| Address2: | DEPARTMENT OF DIAGNOSTIC RADIOLOGY | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181023406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107764822 | ||||||||
| FaxNumber: | 6107764671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 10/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | FRIESS | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6107765325 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0040604000 | 01 | IBC | OTHER | 46716 | 01 | AMERIHEALTH MERCY | OTHER | 1519574 | 01 | GATEWAY HEALTH PLAN | OTHER | 0006736180002 | 05 | PA | MEDICAID | 02410000 | 01 | CBC | OTHER | 068337 | 01 | HIGHMARK BLUE SHIELD GROU | OTHER | CI1114 | 01 | RR MEDICARE GROUP # | OTHER |