Basic Information
| Provider Information | |||||||||
| NPI: | 1851650055 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRISP | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2318 JAMES BOSWELL RD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157138995 | ||||||||
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| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BLVD. | ||||||||
| Address2: | |||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2012 | ||||||||
| LastUpdateDate: | 05/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 2016-01184 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 390200000X | NC | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.