Provider Demographics
NPI:1568550937
Name:CROCKETT, AMY HAIRSTON (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:HAIRSTON
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:HAIRSTON
Other - Last Name:PICKLESIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:890 W FARIS RD
Practice Address - Street 2:STE 470
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4281
Practice Address - Country:US
Practice Address - Phone:864-455-1600
Practice Address - Fax:864-455-3095
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29528207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC295282Medicaid
SC295282Medicaid
SCAA21673640Medicare PIN
SCAA21677951Medicare PIN