Basic Information
| Provider Information | |||||||||
| NPI: | 1609422112 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRESTWOOD HEALTHCARE LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CRESTWOOD MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL DR SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358016455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564294000 | ||||||||
| FaxNumber: | 2564294615 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL DR SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358016455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564294000 | ||||||||
| FaxNumber: | 2564294615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2019 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LALOR | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6292153953 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.