1619963121 NPI number — GARY STEPHEN CRAWFORD M.D.

Table of content: GARY STEPHEN CRAWFORD M.D. (NPI 1619963121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619963121 NPI number — GARY STEPHEN CRAWFORD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAWFORD
Provider First Name:
GARY
Provider Middle Name:
STEPHEN
Provider Name Prefix Text:
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:
1619963121
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 RIVER VINE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLACE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28466-2377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-285-2134
Provider Business Mailing Address Fax Number:
910-285-4610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 MEDICAL VILLAGE DR
Provider Second Line Business Practice Location Address:
UNIT D
Provider Business Practice Location Address City Name:
WALLACE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28466-1668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-285-7592
Provider Business Practice Location Address Fax Number:
910-285-4610
Provider Enumeration Date:
09/21/2005

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:  9401162 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8925388 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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