1639104276 NPI number — ROCHELLE G MCCRANIE P.A.

Table of content: ROCHELLE G MCCRANIE P.A. (NPI 1639104276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639104276 NPI number — ROCHELLE G MCCRANIE P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCRANIE
Provider First Name:
ROCHELLE
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
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:
1639104276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2876
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOULTRIE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31776-2876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-891-9016
Provider Business Mailing Address Fax Number:
229-891-9185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 LAUREL CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOULTRIE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31768-6889
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-890-9016
Provider Business Practice Location Address Fax Number:
229-891-9185
Provider Enumeration Date:
07/12/2006

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: 363AM0700X , with the licence number:  003064 , 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)

  • Identifier: 530785199B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 396284 . This is a "WELLCARE MEDICAID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 132996 . This is a "PEACHSTATE MEDICAID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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