Provider Demographics
NPI:1689755787
Name:SOUTHWELL, CRAIG LONGRIDGE (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:LONGRIDGE
Last Name:SOUTHWELL
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 1:942 CEDAR LAKE CT SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-9715
Mailing Address - Country:US
Mailing Address - Phone:360-481-8186
Mailing Address - Fax:
Practice Address - Street 1:942 CEDAR LAKE CT SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-9715
Practice Address - Country:US
Practice Address - Phone:360-481-8186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026911207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8116519Medicaid
WAE57788Medicare UPIN