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General NPI Number Information
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NPI Number | 1164604187
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Entity Type | Organization
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Legal Business Name | KRYSTAL MEDICAL ASSOCIATES LLC
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Dates
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Enumeration Date | 11/30/2007
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Last Update Date | 08/18/2014
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Provider Practice Location Address
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Address Line | 12150 ANNAPOLIS RD SUITE 100
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City | GLENN DALE
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State | MD
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Zip | 20769-9183
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Country | US
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Telephone | 301-464-7601
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Fax | 866-885-9817
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Provider Business Mailing Address
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Address Line | 12150 ANNAPOLIS RD SUITE 100
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City | GLENN DALE
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State | MD
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Zip | 20769-9183
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Country | US
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Telephone | 301-464-7601
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. NWAEHIHIE H ONYEAGHALA
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Credential | M.D.
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Telephone | 301-486-0100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | D0053461
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | D0053461
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License Number State | MD
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