| Crystal Bastin Md Llc | |
|
4820 Kentucky St South Charleston WV 25309-1310 | |
| (304) 720-0390 | |
| Not Available |
| Full Name | Crystal Bastin Md Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 4820 Kentucky St, South Charleston, West Virginia |
| Authorized Official Name and Position | Shannon G Davis (OFFICE MANAGER) |
| Authorized Official Contact | 3047200390 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Crystal Bastin Md Llc 4820 Kentucky Street South Charleston WV 25309-1364 Ph: (304) 720-0390 | Crystal Bastin Md Llc 4820 Kentucky St South Charleston WV 25309-1310 Ph: (304) 720-0390 |
| NPI Number | 1053539387 |
|---|---|
| Provider Enumeration Date | 04/23/2007 |
| Last Update Date | 11/12/2013 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1053539387 | NPI | - | NPPES |
| 1801865001 | Medicaid | WV |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 20368 (West Virginia) | Primary |
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