1205990207 NPI number — DR. RUSSELL S CRAVEY M.D.

Table of content: DR. RUSSELL S CRAVEY M.D. (NPI 1205990207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205990207 NPI number — DR. RUSSELL S CRAVEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAVEY
Provider First Name:
RUSSELL
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205990207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 294869
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERRVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78029-4869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-257-4417
Provider Business Mailing Address Fax Number:
830-257-1480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 WATER ST
Provider Second Line Business Practice Location Address:
STE. E100
Provider Business Practice Location Address City Name:
KERRVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78028-3523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-257-4417
Provider Business Practice Location Address Fax Number:
830-257-1480
Provider Enumeration Date:
12/21/2006

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: 207W00000X , with the licence number:  J6394 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8A7630 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00158163 . This is a "MEDICARE RR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 122036005 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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