Basic Information
Provider Information | |||||||||
NPI: | 1942960786 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CRYSTAL RIVER HMA PHYSICIAN MANAGEMENT LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CRYSTAL RIVER HMA PHYSICIAN MANAGEMENT LLC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 689022 | ||||||||
Address2: |   | ||||||||
City: | FRANKLIN | ||||||||
State: | TN | ||||||||
PostalCode: | 370689022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6154657211 | ||||||||
FaxNumber: | 8778929815 | ||||||||
Practice Location | |||||||||
Address1: | 3475 S SUNCOAST BLVD | ||||||||
Address2: |   | ||||||||
City: | HOMOSASSA | ||||||||
State: | FL | ||||||||
PostalCode: | 344482322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3527652010 | ||||||||
FaxNumber: | 3527652017 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2021 | ||||||||
LastUpdateDate: | 03/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACKSON | ||||||||
AuthorizedOfficialFirstName: | JENNIFER | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | SR DIR ONBOARDING & PROV ENROLLMENT | ||||||||
AuthorizedOfficialTelephone: | 6154653334 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 208600000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | PENDING | 05 | FL |   | MEDICAID |