Provider Demographics
NPI:1174584221
Name:CRAWFORD, GRACE (MD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FREEDOM WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6258
Mailing Address - Country:US
Mailing Address - Phone:706-733-0188
Mailing Address - Fax:706-481-6791
Practice Address - Street 1:1 FREEDOM WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6258
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:706-729-5922
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060571207R00000X
NY235391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02641514Medicaid
VA1174584221Medicaid
VA223858253OtherTAX ID
NY02641514Medicaid
VA1174584221Medicaid