MEDICARE: DR. CHARLES J CRIST M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME9468	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00349497	OTHER	FL	RAILROAD MEDICARE NUMBER

General Provider Information

NPI Number	:	1700889383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES J CRIST M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1830
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33757-1830
Country	:	US
Telephone Number	:	727-532-0002
Fax Number	:	727-532-1318

Provider Business Practice Location Address
First Line	:	3085 DR MARTIN LUTHER KING ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33704-2034
Country	:	US
Telephone Number	:	727-822-3238
Fax Number	:	727-823-1278

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	07/08/2007

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