Healthcare Provider Details

I. General information

NPI: 1588690382
Provider Name (Legal Business Name): KELLY C GROW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY B CRAWFORD M.D.

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 N MILLEDGE AVE STE B
ATHENS GA
30601-3806
US

IV. Provider business mailing address

1001 SUMMIT BLVD STE 200
BROOKHAVEN GA
30319-6410
US

V. Phone/Fax

Practice location:
  • Phone: 706-548-0008
  • Fax: 706-369-9673
Mailing address:
  • Phone: 770-989-1668
  • Fax: 706-369-9673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number051353
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: