Basic Information
| Provider Information | |||||||||
| NPI: | 1184114175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRISP | ||||||||
| FirstName: | LADDIE | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 MED TECH PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233026567 | ||||||||
| FaxNumber: | 2083752217 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK BLVD STE 255W | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376207430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763782026 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2018 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MRM-1726 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 0101272131 | VA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 63278 | TN | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.