ABIGAIL CRISOSTOMO, MD - NPI NUMBER 1720347867

Summary

Provider Name: ABIGAIL CRISOSTOMO, MD

NPI Number: 1720347867

Clasification: Family Medicine (207Q00000X)

Organization: MERCY CLINIC SPRINGFIELD COMMUNITIES

Address:
1605 MARTIN SPRINGS DR
STE 210
ROLLA, MO
ZIP 65401

Phone Number: (573) 458-6326



Detailed Information

Abigail Crisostomo, MD is a family physician in Rolla, MO with 12 years of experience. The provider is family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity. The assigned NPI number for this provider is 1720347867 and is registered as an individual entity type.

The NPPES NPI record indicates the provider is a female.

The provider's business address is:

1605 MARTIN SPRINGS DR
STE 210
ROLLA, MO
ZIP 65401-931
Phone: (573) 458-6326
Fax: (573) 458-6763

The enumeration date for this NPI number is 5/10/2012 and was last updated on 12/20/2012.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 207Q00000X Family Medicine 2012003234 MO Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 1720347867 MEDICAID MO
2 431560263 OTHER MO TRICARE
3 P01089883 OTHER MO RR MCR
4 132300229 MEDICARE PIN MO

NPI Record

No. Field Name Field Value Field Definition 1
1 NPI 1720347867 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 1 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Provider Last Name Legal Name CRISOSTOMO The last name of the provider. If the provider is an individual, this is the legal name.
4 Provider First Name ABIGAIL The first name of the provider, if the provider is an individual.
5 Provider Credential Text MD The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.
6 Provider First Line Business Practice Location Address 1605 MARTIN SPRINGS DR The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
7 Provider Second Line Business Practice Location Address STE 210 The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
8 Provider Business Practice Location Address City Name ROLLA The city name in the location address of the provider being identified.
9 Provider Business Practice Location Address State Name MO The State code in the location of the provider being identified.
10 Provider Business Practice Location Address Postal Code 654012931 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
11 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
12 Provider Business Practice Location Address Telephone Number 5734586326 The telephone number associated with the location address of the provider being identified.
13 Provider Business Practice Location Address Fax Number 5734586763 The fax number associated with the location address of the provider being identified.
14 Provider Enumeration Date 5/10/2012 The date the provider was assigned a unique identifier (assigned an NPI).
15 Last Update Date 12/20/2012 The date that a record was last updated or changed.
16 Provider Gender Code F The code designating the provider’s gender if the provider is a person.
17 Healthcare Provider Taxonomy Code 1 207Q00000X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
18 Provider License Number 1 2012003234 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
19 Provider License Number State Code 1 MO The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
20 Healthcare Provider Primary Taxonomy Switch 1 Y
21 Other Provider Identifier 1 1720347867 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
22 Other Provider Identifier Type Code 1 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
23 Other Provider Identifier State 1 MO
24 Other Provider Identifier 2 431560263 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
25 Other Provider Identifier Type Code 2 01 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
26 Other Provider Identifier State 2 MO
27 Other Provider Identifier Issuer 2 TRICARE
28 Other Provider Identifier 3 P01089883 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
29 Other Provider Identifier Type Code 3 01 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
30 Other Provider Identifier State 3 MO
31 Other Provider Identifier Issuer 3 RR MCR
32 Other Provider Identifier 4 132300229 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
33 Other Provider Identifier Type Code 4 08 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
34 Other Provider Identifier State 4 MO
35 Is Sole Proprietor N Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No

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This page was last updated on: 3/10/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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