Provider Demographics
NPI:1558362897
Name:CRUMP, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:CRUMP
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 1:708 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4827
Mailing Address - Country:US
Mailing Address - Phone:770-228-5402
Mailing Address - Fax:770-412-6917
Practice Address - Street 1:708 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4827
Practice Address - Country:US
Practice Address - Phone:770-228-5402
Practice Address - Fax:770-412-6917
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA28957207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581936002OtherTAX ID
GA000332758AMedicaid
GA581936002OtherTAX ID
GAD29217Medicare UPIN