Provider Demographics
NPI:1023147493
Name:CRESTVIEW MEDICAL CENTER P A
Entity type:Organization
Organization Name:CRESTVIEW MEDICAL CENTER P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:OGUNWANDE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:302-762-4545
Mailing Address - Street 1:1800 N BROOM ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19802-3809
Mailing Address - Country:US
Mailing Address - Phone:302-762-4545
Mailing Address - Fax:302-762-9086
Practice Address - Street 1:1800 N BROOM ST
Practice Address - Street 2:SUITE 109
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802-3809
Practice Address - Country:US
Practice Address - Phone:302-762-4545
Practice Address - Fax:302-762-9086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0004996305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEG01637Medicare ID - Type Unspecified