Healthcare Provider Details

I. General information

NPI: 1265815005
Provider Name (Legal Business Name): KATHRYN CROWE MCCUTCHEON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 AUGUSTA WEST PKWY
AUGUSTA GA
30909
US

IV. Provider business mailing address

1230 AUGUSTA WEST PKWY
AUGUSTA GA
30909-1854
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-0380
  • Fax:
Mailing address:
  • Phone: 706-868-0380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7579
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: