Healthcare Provider Details

I. General information

NPI: 1396969200
Provider Name (Legal Business Name): CRYSTAL HAMILTON MCMAHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4003 KRESGE WAY STE 115
LOUISVILLE KY
40207-4652
US

IV. Provider business mailing address

PO BOX 950248
LOUISVILLE KY
40295-0248
US

V. Phone/Fax

Practice location:
  • Phone: 502-897-8163
  • Fax: 502-897-8052
Mailing address:
  • Phone: 502-489-5730
  • Fax: 502-489-5753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number42203
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: