Provider Demographics
NPI:1912287749
Name:DR. EDWARD FRANKLIN CROCKETT, III
Entity Type:Organization
Organization Name:DR. EDWARD FRANKLIN CROCKETT, III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:256-764-1263
Mailing Address - Street 1:3502 CLOVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35633-1302
Mailing Address - Country:US
Mailing Address - Phone:256-764-1263
Mailing Address - Fax:256-764-9611
Practice Address - Street 1:3502 CLOVERDALE RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35633-1302
Practice Address - Country:US
Practice Address - Phone:256-764-1263
Practice Address - Fax:256-764-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8871172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000012290Medicaid
TN0046614OtherBCBS TENNESSEE
AL12290OtherBCBS
000012290OtherMEDICARE
TN0046614OtherBCBS TENNESSEE
000012290OtherMEDICARE