1568550937 NPI number — AMY HAIRSTON CROCKETT M.D.

Table of content: AMY HAIRSTON CROCKETT M.D. (NPI 1568550937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568550937 NPI number — AMY HAIRSTON CROCKETT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROCKETT
Provider First Name:
AMY
Provider Middle Name:
HAIRSTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PICKLESIMER
Provider Other First Name:
AMY
Provider Other Middle Name:
HAIRSTON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568550937
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 INDEPENDENCE PT STE 212
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29615-4536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
890 W FARIS RD
Provider Second Line Business Practice Location Address:
STE 470
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29605-4281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-455-1600
Provider Business Practice Location Address Fax Number:
864-455-3095
Provider Enumeration Date:
10/11/2006

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: 207VM0101X , with the licence number:  29528 , 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: 295282 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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