Basic Information
| Provider Information | |||||||||
| NPI: | 1194709550 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | CRISOLOGO | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | ALBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2151 OLD ROCKY RIDGE ROAD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352167251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059891080 | ||||||||
| FaxNumber: | 2059891087 | ||||||||
| Practice Location | |||||||||
| Address1: | 1912 ALABAMA HWY 157 | ||||||||
| Address2: | CULLMAN REGIONAL MEDICAL CENTER | ||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350580000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567372637 | ||||||||
| FaxNumber: | 2567346257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 09/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD.14016 | AL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2777 | 01 | AL | HEALTHSPRING OF ALABAMA | OTHER | 051086833 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 000086833 | 05 | AL | MEDICAID | 2777 | 01 | HEALTH STRATEGIES INC | OTHER | 631003288 | 01 | TRICARE (GROUP) | OTHER |