NPIMap

Organization Active NPI

Crestview Hospital Corporation

  • Family Medicine Physician
  • Crestview, FL
National Provider Identifier
1629026133
Registry record updated Mar 18, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CRESTVIEW HOSPITAL CORPORATION
Practice address
127C E. Redstone Ave
Crestview, FL 32539-5356
Phone
(850) 423-0061
NPI assigned
May 5, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 18, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jennifer L Jackson
Title
Sr Dir Onboarding & Prov Enrollment
Phone
(615) 465-3334

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Rural Health Clinic/Center 261QR1300X

Addresses

Primary practice location

127C E. Redstone Ave
Crestview, FL 32539-5356

Mailing address

330 Franklin Rd # 135a-316
Brentwood, TN 37027-3280
Phone (615) 465-7000

Other names 1

  • Gateway Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040123000275 FL Part B Supplier - Clinic/Group Practice 3678472313 Receives reassigned benefits from 23 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Crestview, FL; Defuniak Springs, FL

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Gateway Medical Clinic9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1146787200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1647561600000",
    "number": "1629026133",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "330 FRANKLIN RD # 135A-316",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370273280",
            "telephone_number": "615-465-7000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "127C E. REDSTONE AVE",
            "city": "CRESTVIEW",
            "state": "FL",
            "postal_code": "325395356",
            "telephone_number": "850-423-0061"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRESTVIEW HOSPITAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-05",
        "last_updated": "2022-03-18",
        "certification_date": "2022-02-14",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "SR DIR ONBOARDING & PROV ENROLLMENT",
        "authorized_official_telephone_number": "615-465-3334"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Gateway Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Gateway Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Crestview, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.