Healthcare Provider Details

I. General information

NPI: 1790988350
Provider Name (Legal Business Name): JONATHAN G CRISP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE HOSPITAL DR
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-4400
  • Fax: 573-884-5994
Mailing address:
  • Phone: 573-882-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberA95667
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2017032649
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: