Healthcare Provider Details

I. General information

NPI: 1255522629
Provider Name (Legal Business Name): BETHANY CRISPIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETHANY COOKSTON MD

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 MAIN ST S
MC KEE KY
40447-7089
US

IV. Provider business mailing address

1010 MAIN ST S
MC KEE KY
40447-7089
US

V. Phone/Fax

Practice location:
  • Phone: 606-287-7104
  • Fax: 606-287-4409
Mailing address:
  • Phone: 606-287-7104
  • Fax: 606-287-4409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number42913
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: