Provider Demographics
NPI:1316900434
Name:SWANN, CRAIG (DO)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:SWANN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 171
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25271-0171
Mailing Address - Country:US
Mailing Address - Phone:304-372-3506
Mailing Address - Fax:
Practice Address - Street 1:122 PINNELL ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:WV
Practice Address - Zip Code:25271-9101
Practice Address - Country:US
Practice Address - Phone:304-372-3506
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0054582000Medicaid
WVSW0803444Medicare ID - Type Unspecified
WV0054582000Medicaid