Provider Demographics
NPI:1962568675
Name:CRYSTAL PLASTIC SURGEONS, INC.
Entity type:Organization
Organization Name:CRYSTAL PLASTIC SURGEONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KREITZBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-668-4065
Mailing Address - Street 1:3925 EMBASSY PKWY
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44333-1763
Mailing Address - Country:US
Mailing Address - Phone:330-668-4065
Mailing Address - Fax:330-670-4160
Practice Address - Street 1:3925 EMBASSY PKWY
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44333-1763
Practice Address - Country:US
Practice Address - Phone:330-668-4065
Practice Address - Fax:330-670-4160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCJ8526OtherRAILROAD MEDICARE
OH0150554Medicaid
OH=========3A01OtherANTHEM BC BS
OH=========3A01OtherANTHEM BC BS