1952444952 NPI number — MR. JOSEPH GRATTON CROCKETT III OTR

Table of content: (NPI 1679399851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952444952 NPI number — MR. JOSEPH GRATTON CROCKETT III OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROCKETT
Provider First Name:
JOSEPH
Provider Middle Name:
GRATTON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
OTR
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:
1952444952
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 238
Provider Second Line Business Mailing Address:
1200 WESTBROOK ROAD COMMERCE, GA 30530
Provider Business Mailing Address City Name:
YOUNG HARRIS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30582-0238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-379-4068
Provider Business Mailing Address Fax Number:
706-379-0640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6724 MORGAN CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YOUNG HARRIS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30582-2551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-379-4068
Provider Business Practice Location Address Fax Number:
706-379-0640
Provider Enumeration Date:
02/15/2007

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: 225XP0200X , with the licence number:  OT000783 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225XP0200X , with the licence number: 6316 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00969647A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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