Provider Demographics
NPI:1770519951
Name:CROCKER, EDWARD FRANK JR (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:FRANK
Last Name:CROCKER
Suffix:JR
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 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:255 BAPTIST BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2011
Practice Address - Country:US
Practice Address - Phone:662-244-2288
Practice Address - Fax:662-244-2289
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17871208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05082097Medicaid
AL731-04786OtherBCBS AL
MS512I060026Medicare PIN
E60530Medicare UPIN
MSE60530Medicare UPIN