| Organization Name: | KRYSTAL MEDICAL ASSOCIATES LLC |
| NPI Number: | 1164604187 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | NWAEHIHIE H ONYEAGHALA (PRESIDENT) |
| Mailing Address: | 12150 Annapolis Rd Suite 100 Glenn Dale |
| State: | MD US |
| Postal Code: | 207699183 |
| Phone Number: | 3014647601 |
| Fax Number: | 8668859817 |
| NPI Enumeration Date: | 11/30/2007 |
| NPI Last Update Date: | 08/18/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QM1300X |
| License Number: | D0053461 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MD |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Multi-Specialty |
| Taxonomy Definition: | |