Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | SC005698 | PA |
N | 222Z00000X | Podiatrist | SC005698 | PA |
N | 213EP1101X | Primary Podiatric Medicine | SC005698 | PA |
N | 2081S0010X | Sports Medicine | SC005698 | PA |
N | 213ES0000X | Sports Medicine | SC005698 | PA |
Y | 213ES0103X | Foot & Ankle Surgery | SC005698 | PA |
NPI | 1306806765 |
---|---|
Provider Name | Brian Dale Crispell |
First Address | Philadelphia, PA 19130-3143 |
Second Address | Media, PA 19063-5105 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2006 |
Last Update Date | 13/06/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1015531700005 | (05) | PA |
329832 | MEDICARE PTAN (01) | PA |