| Krystal Medical Associates | |
|
12150 Annapolis Rd Suite 100 Glenn Dale MD 20769-9183 | |
| (301) 464-7601 | |
| (866) 885-9817 |
| Full Name | Krystal Medical Associates |
|---|---|
| Speciality | Clinic/Center |
| Location | 12150 Annapolis Rd, Glenn Dale, Maryland |
| Authorized Official Name and Position | Nwaehihie H Onyeaghala (PRESIDENT) |
| Authorized Official Contact | 3014860100 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Krystal Medical Associates 12150 Annapolis Rd Suite 100 Glenn Dale MD 20769-9183 Ph: (301) 464-7601 | Krystal Medical Associates 12150 Annapolis Rd Suite 100 Glenn Dale MD 20769-9183 Ph: (301) 464-7601 |
| NPI Number | 1164604187 |
|---|---|
| Provider Enumeration Date | 11/30/2007 |
| Last Update Date | 08/18/2014 |
| Medicare PECOS PAC ID | 8426247339 |
|---|---|
| Medicare Enrollment ID | O20110107000538 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1164604187 | NPI | - | NPPES |
| 402647100 | Medicaid | MD | |
| 010012902 | Medicaid | VA | |
| 034934800 | Medicaid | DC |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | D0053461 (Maryland) | Secondary |
| 261QP2300X | Clinic/center - Primary Care | D0053461 (Maryland) | Primary |
| Provider Name | Nwaehihie H Onyeaghala |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1114938800 PECOS PAC ID: 1759570666 Enrollment ID: I20110107000465 |
| Provider Name | Carine Gouetso Ndeko |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1306321443 PECOS PAC ID: 3476921339 Enrollment ID: I20221125000375 |
| Provider Name | Isaac Owusu |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1265131536 PECOS PAC ID: 8022469089 Enrollment ID: I20240129001717 |
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