1477931236 NPI number — DR. KRISTINA JHEANELLE MCCAW MD

Table of content: DR. KRISTINA JHEANELLE MCCAW MD (NPI 1477931236)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477931236 NPI number — DR. KRISTINA JHEANELLE MCCAW MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCAW
Provider First Name:
KRISTINA
Provider Middle Name:
JHEANELLE
Provider Name Prefix Text:
DR.
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:
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:
1477931236
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
12/21/2015
NPI Reactivation Date:
12/29/2015

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 WESTVIEW DRIVE, SW
Provider Second Line Business Mailing Address:
MOREHOUSE SCHOOL OF MEDICINE, DEPARTMENT OF INTERNAL ME
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-756-1325
Provider Business Mailing Address Fax Number:
404-756-1313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 WESTVIEW DRIVE, SW
Provider Second Line Business Practice Location Address:
MOREHOUSE SCHOOL OF MEDICINE, DEPARTMENT OF INTERNAL ME
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-756-1325
Provider Business Practice Location Address Fax Number:
404-756-1313
Provider Enumeration Date:
05/13/2015

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 079271 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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