1255325536 NPI number — MARTHA H CRENSHAW MD

Table of content: MARTHA H CRENSHAW MD (NPI 1255325536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255325536 NPI number — MARTHA H CRENSHAW MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRENSHAW
Provider First Name:
MARTHA
Provider Middle Name:
H
Provider Name Prefix Text:
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:
1255325536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1805 PARKE PLAZA CIR
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
STONE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30087-3498
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-469-7000
Provider Business Mailing Address Fax Number:
770-879-0436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1805 PARKE PLAZA CIR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
STONE MOUNTAIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30087-3498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-469-7000
Provider Business Practice Location Address Fax Number:
770-879-0436
Provider Enumeration Date:
09/01/2005

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:  023580 , 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: 00247024A1 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0528626 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 080027160 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 151302 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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