Provider Demographics
NPI:1477661197
Name:CRAIN, COREY K (MD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:K
Last Name:CRAIN
Suffix:
Gender:M
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:803-324-5256
Mailing Address - Fax:803-328-0440
Practice Address - Street 1:1721 EBENEZER RD STE 175
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1188
Practice Address - Country:US
Practice Address - Phone:803-324-5256
Practice Address - Fax:803-328-0440
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12371208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC123716Medicaid
SCC611132366Medicare PIN
SC123716Medicaid