Basic Information
| Provider Information | |||||||||
| NPI: | 1720158843 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRISOLOGO | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 RIBAUT RD | ||||||||
| Address2: | BMAC CREDENTIALING | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435225674 | ||||||||
| FaxNumber: | 8435225678 | ||||||||
| Practice Location | |||||||||
| Address1: | BEAUFORT MEMORIAL LOWCOUNTRY MEDICAL GROUP | ||||||||
| Address2: | 300 MIDTOWN DRIVE | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299065200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437700404 | ||||||||
| FaxNumber: | 8442962309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/24/2019 | ||||||||
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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 | 207RG0100X | 24000 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | T81480 | 05 | SC | MEDICAID |