Provider Demographics
NPI:1427063379
Name:CRESTWOOD FAMILY MEDICINE
Entity type:Organization
Organization Name:CRESTWOOD FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:HEFNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:502-243-3161
Mailing Address - Street 1:6106 CRESTWOOD STA STE A
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-9473
Mailing Address - Country:US
Mailing Address - Phone:502-243-3161
Mailing Address - Fax:502-243-3164
Practice Address - Street 1:6106 CRESTWOOD STA STE A
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-9473
Practice Address - Country:US
Practice Address - Phone:502-243-3161
Practice Address - Fax:502-243-3164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02614207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64000391Medicaid
KY64000391Medicaid
KY1798701Medicare ID - Type Unspecified