1104802859 NPI number — DR. MICHAEL RAYMOND CRAM

Table of content: DR. MICHAEL RAYMOND CRAM (NPI 1104802859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104802859 NPI number — DR. MICHAEL RAYMOND CRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAM
Provider First Name:
MICHAEL
Provider Middle Name:
RAYMOND
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1104802859
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9735 KINCEY AVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
HUNTERSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28078-9118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-414-2870
Provider Business Mailing Address Fax Number:
704-414-2860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 MEDICAL PARK RD
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28117-8578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-660-3322
Provider Business Practice Location Address Fax Number:
704-660-3330
Provider Enumeration Date:
12/15/2005

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: 174400000X , with the licence number:  9900025 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 9900025 , 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: 891188F , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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