Provider Demographics
NPI:1790017416
Name:CHARLES P CRAIG MD PC
Entity Type:Organization
Organization Name:CHARLES P CRAIG MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:POE
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL DOCTOR
Authorized Official - Phone:734-528-9111
Mailing Address - Street 1:4870 W CLARK RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1104
Mailing Address - Country:US
Mailing Address - Phone:734-528-9111
Mailing Address - Fax:734-528-9082
Practice Address - Street 1:4870 W CLARK RD
Practice Address - Street 2:SUITE 204
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1104
Practice Address - Country:US
Practice Address - Phone:734-528-9111
Practice Address - Fax:734-528-9082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICC052386207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4414481Medicaid
MI4414481Medicaid
MI0N51960Medicare PIN