Organization
CRESTVIEW HOSPITAL CORPORATION
Active
Parent organization
CRESTVIEW HOSPITAL CORPORATION
Other names
Gateway Medical Clinic DeFuniak
Organization subpart
Yes
Provider details
NPI number
Legal business name
CRESTVIEW HOSPITAL CORPORATION
Authorized official
JENNIFER L JACKSON (SR DIR ONBOARDING & PROV ENROLLMENT)
(615) 465-3334
Entity
Organization
Contact information
Practice address
650 US HIGHWAY 331 S, STE. 4, DEFUNIAK SPRINGS, FL 32435-3349
(850) 892-3366
Mailing address
7100 COMMERCE WAY, STE. 180, BRENTWOOD, TN 37027-2829
(615) 465-7626
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
207R00000X
Internal Medicine Physician
—
—
261QR1300X
Rural Health Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
40043A
BCBS OF FL
FL
05
—
660058101
—
FL
Enumeration date
05/05/2006
Last updated
03/18/2022
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