Basic Information
| Provider Information | |||||||||
| NPI: | 1801844618 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRYSTAL CITY EMERGENCY SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 827431 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191827431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048051300 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Practice Location | |||||||||
| Address1: | HIGHWAY 61 SOUTH | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369331000 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAUCHERT | ||||||||
| AuthorizedOfficialFirstName: | EUGENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9197684392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 363A00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 426403 | 01 | MO | HEALTHLINK | OTHER | 124884 | 01 | MO | BLUE CROSS & BLUE SHIELD | OTHER | 137529 | 01 | MO | UMWA | OTHER |