NPIMap

Organization Active NPI

Crestview Hospital Corporation

Doing business as Gateway Medical Clinic DeFuniak

  • Family Medicine Physician
  • Defuniak Springs, FL
National Provider Identifier
1902854425
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
Doing business as
Gateway Medical Clinic DeFuniak
Practice address
650 US Highway 331 S
Ste. 4
Defuniak Springs, FL 32435-3349
Phone
(850) 892-3366
NPI assigned
May 5, 2006
Organization subpart
Yes
Parent organization
CRESTVIEW HOSPITAL CORPORATIONAs reported in NPPES

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

650 US Highway 331 S
Ste. 4
Defuniak Springs, FL 32435-3349

Mailing address

7100 Commerce Way
Ste. 180
Brentwood, TN 37027-2829
Phone (615) 465-7626

Other identifiers 2

IdentifierTypeStateIssuer
660058101MedicaidFL
40043AOtherFLBCBS OF FL

Other names 1

  • Gateway Medical Clinic DeFuniak 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
Crestview Hospital Corporation9 organizations share this tax ID, including this one
Part of
Crestview Hospital Corporation

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": "1902854425",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7100 COMMERCE WAY",
            "address_2": "STE. 180",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370272829",
            "telephone_number": "615-465-7626"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "650 US HIGHWAY 331 S",
            "address_2": "STE. 4",
            "city": "DEFUNIAK SPRINGS",
            "state": "FL",
            "postal_code": "324353349",
            "telephone_number": "850-892-3366"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRESTVIEW HOSPITAL CORPORATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CRESTVIEW HOSPITAL CORPORATION",
        "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": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "660058101",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF FL",
            "identifier": "40043A",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Gateway Medical Clinic DeFuniak",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Gateway Medical Clinic DeFuniak",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Defuniak Springs, 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.