Basic Information
| Provider Information | |||||||||
| NPI: | 1952376410 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRYSTAL RUN HEALTHCARE PHYSICIANS LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 CRYSTAL RUN RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109414028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457036999 | ||||||||
| FaxNumber: | 8457036297 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 CRYSTAL RUN RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109414028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457036999 | ||||||||
| FaxNumber: | 8457036297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TEITELBAUM | ||||||||
| AuthorizedOfficialFirstName: | HAL | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 8457036999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD, JD, MBA | ||||||||
| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0200X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RE0101X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0300X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RH0003X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RI0011X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207K00000X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207P00000X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207RI0200X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RM1200X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Magnetic Resonance Imaging (MRI) | 208D00000X | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 02409709 | 05 | NY | MEDICAID |