Provider Demographics
NPI:1447438486
Name:CROSS CREEK MEDICAL PA
Entity type:Organization
Organization Name:CROSS CREEK MEDICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-877-6393
Mailing Address - Street 1:1381A CROSS CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-3729
Mailing Address - Country:US
Mailing Address - Phone:850-877-6393
Mailing Address - Fax:850-877-6813
Practice Address - Street 1:1381 CROSS CREEK CIR
Practice Address - Street 2:SUITE A
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-3723
Practice Address - Country:US
Practice Address - Phone:850-877-6393
Practice Address - Fax:850-877-6393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0071014FLME207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250984900Medicaid
FLDF9814OtherRAILROAD MEDICARE
FL003457000Medicaid
FL250984900Medicaid
FLK4140Medicare PIN