Healthcare Provider Details

I. General information

NPI: 1679404214
Provider Name (Legal Business Name): CRESTLINE MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29399 US HWY 19N SUITE 150
CLEARWATER FL
33761
US

IV. Provider business mailing address

29399 US HWY 19N SUITE 150
CLEARWATER FL
33761
US

V. Phone/Fax

Practice location:
  • Phone: 727-258-3743
  • Fax:
Mailing address:
  • Phone: 727-258-3743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name: KASEY ROBERTSON
Title or Position: CAO
Credential: CHIEF ADMIN OFFICER
Phone: 210-422-4613