1124134762 NPI number — AMY MARIE CRAYCRAFT PAYNE MD

Table of content: AMY MARIE CRAYCRAFT PAYNE MD (NPI 1124134762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124134762 NPI number — AMY MARIE CRAYCRAFT PAYNE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAYCRAFT PAYNE
Provider First Name:
AMY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRAYCRAFT
Provider Other First Name:
AMY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124134762
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3686 WHEELER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30909-6520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-922-6300
Provider Business Mailing Address Fax Number:
706-922-6303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 WEST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH AUGUSTA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29841-3350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-279-1030
Provider Business Practice Location Address Fax Number:
803-278-1344
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  58048 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 30432 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 102I081896 . This is a "MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 058408 . This is a "STATE OF GEORGIA LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 30432 . This is a "SC MEDICAL LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: G58408 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20-30432 . This is a "SC CONTROLLED SUBSTANCES" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: SC5305D839 . This is a "MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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