Provider Demographics
NPI:1902854425
Name:CRESTVIEW HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:CRESTVIEW HOSPITAL CORPORATION
Other - Org Name:GATEWAY MEDICAL CLINIC DEFUNIAK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIR ONBOARDING & PROV ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:7100 COMMERCE WAY
Mailing Address - Street 2:STE. 180
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2829
Mailing Address - Country:US
Mailing Address - Phone:615-465-7626
Mailing Address - Fax:
Practice Address - Street 1:650 US HIGHWAY 331 S
Practice Address - Street 2:STE. 4
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-3349
Practice Address - Country:US
Practice Address - Phone:850-892-3366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRESTVIEW HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-05
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660058101Medicaid
FL40043AOtherBCBS OF FL