Provider Demographics
NPI:1295726867
Name:CREWS, JACK (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:CREWS
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 1:100 PROFESSIONAL PL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3874
Mailing Address - Country:US
Mailing Address - Phone:770-384-3351
Mailing Address - Fax:
Practice Address - Street 1:100 PROFESSIONAL PL
Practice Address - Street 2:SUITE 204
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3874
Practice Address - Country:US
Practice Address - Phone:770-384-3351
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010514207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA552328OtherBLUE CROSS
GA00677201AMedicaid
GA552328OtherBLUE CROSS
GAD90976Medicare UPIN