Basic Information
| Provider Information | |||||||||
| NPI: | 1417921362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRICKENBERGER | ||||||||
| FirstName: | DALLAS | ||||||||
| MiddleName: | PAYNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 RIVERSIDE CIR | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240164955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407251226 | ||||||||
| FaxNumber: | 5408575306 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 RIVERSIDE CIR | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240164955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407251226 | ||||||||
| FaxNumber: | 5408575306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 03/10/2014 | ||||||||
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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 | 207X00000X | 0101-017904 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1417921362 | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | 1417921362 | 01 | VA | VA PREMIER | OTHER | 1417921362 | 01 | VA | GATEWAY | OTHER | 1417921362 | 01 | VA | AETNA | OTHER | 1417921362 | 01 | VA | MAJESTACARE | OTHER | 1417921362 | 01 | VA | INTOTAL | OTHER | 1417921362 | 01 | VA | SOUTHERN HEALTH/CARENET/CARELINK/COVENTRY | OTHER | 540506332004 | 01 | VA | TRICARE/CHAMPUS | OTHER | 1417921362 | 01 | VA | ANTHEM | OTHER | 1417921362 | 01 | VA | HEALTHKEEPERS | OTHER | 1417921362 | 01 | VA | HEALTHKEEPERS PLUS | OTHER | 1417921362 | 01 | VA | CIGNA | OTHER | 1417921362 | 01 | VA | UMWA | OTHER | 1417921362 | 01 | VA | HUMANA MEDICARE | OTHER | 1417921362 | 01 | VA | UNITED HEALTHCARE | OTHER | P200030655 | 01 | VA | RAILROAD MEDICARE | OTHER | 1417921362 | 01 | VA | OPTIMA HEALTH PLAN | OTHER | 1417921362 | 05 | VA | MEDICAID | 0097064000 | 01 | VA | MEDICAID OF WEST VIRGINIA | OTHER | 371194700 | 01 | VA | BLACK LUNG | OTHER |