Provider Demographics
NPI:1669632014
Name:CRISP GENERAL INTERNAL MEDICINE INC
Entity Type:Organization
Organization Name:CRISP GENERAL INTERNAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-273-4989
Mailing Address - Street 1:1801 QUAIL RUN
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-2096
Mailing Address - Country:US
Mailing Address - Phone:229-273-4989
Mailing Address - Fax:
Practice Address - Street 1:416 E 4TH AVE STE B
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3729
Practice Address - Country:US
Practice Address - Phone:229-273-8501
Practice Address - Fax:229-273-2515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060593261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty