Healthcare Provider Details

I. General information

NPI: 1235706524
Provider Name (Legal Business Name): JORDAN LEE CRAMER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0006
US

IV. Provider business mailing address

7062 KINGSFISHER PASS
GRANITEVILLE SC
29829-3999
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-4467
  • Fax: 706-727-9081
Mailing address:
  • Phone: 803-417-2798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number12917
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: