Provider Demographics
NPI:1194586420
Name:CROSSOVER HEALTH MEDICAL GROUP
Entity type:Organization
Organization Name:CROSSOVER HEALTH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSING AND CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-500-2661
Mailing Address - Street 1:2 DESTINY WAY FL 1
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-8100
Mailing Address - Country:US
Mailing Address - Phone:817-474-6333
Mailing Address - Fax:817-491-5925
Practice Address - Street 1:2 DESTINY WAY FL 1
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:TX
Practice Address - Zip Code:76262-8100
Practice Address - Country:US
Practice Address - Phone:817-474-6333
Practice Address - Fax:817-491-5925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty