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Organization
CRYSTAL BASTIN MD LLC
Active
Organization
CRYSTAL BASTIN MD LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SHANNON G DAVIS (OFFICE MANAGER)
(304) 720-0390
Entity
Organization
Contact information
Practice address
4820 KENTUCKY ST, SOUTH CHARLESTON, WV 25309-1310
(304) 720-0390
Mailing address
4820 KENTUCKY STREET, SOUTH CHARLESTON, WV 25309-1364
(304) 720-0390
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
20368
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1801865001
—
WV
Enumeration date
04/23/2007
Last updated
11/12/2013
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