Provider Demographics
NPI:1265547301
Name:MCCRARY, RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:MCCRARY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:MCCRARY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:JMM SUITE 2525
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-9528
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:1285 SPRINGBRIDGE STREET. SUITE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3423
Practice Address - Country:US
Practice Address - Phone:228-896-6441
Practice Address - Fax:228-896-6576
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09363208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114228Medicaid
MS$$$$$$$$$HOtherBCBS
MS$$$$$$$$$BOtherBCBS
MS$$$$$$$$$COtherBCBS
MS$$$$$$$$$EOtherBCBS
MS$$$$$$$$$IOtherBCBS
MS$$$$$$$$$GOtherBCBS
MSD92618Medicare UPIN
MS302I372171Medicare PIN
MS302I375966Medicare PIN
MS370000183Medicare ID - Type Unspecified