1770519951 NPI number — EDWARD FRANK CROCKER JR. M.D.

Table of content: EDWARD FRANK CROCKER JR. M.D. (NPI 1770519951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770519951 NPI number — EDWARD FRANK CROCKER JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROCKER
Provider First Name:
EDWARD
Provider Middle Name:
FRANK
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
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:
1770519951
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
965 RIDGE LAKE BLVD STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38120-9446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-227-3255
Provider Business Mailing Address Fax Number:
901-227-8591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
255 BAPTIST BLVD
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39705-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-244-2288
Provider Business Practice Location Address Fax Number:
662-244-2289
Provider Enumeration Date:
06/23/2006

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: 208G00000X , with the licence number:  17871 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 05082097 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 731-04786 . This is a "BCBS AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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