Healthcare Provider Details

I. General information

NPI: 1770787582
Provider Name (Legal Business Name): MARCUS H. CRAWFORD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 ACWORTH DUE WEST ROAD BUILDING 200, SUITE 220
KENNESAW GA
30144
US

IV. Provider business mailing address

3450 ACWORTH DUE WEST ROAD BUILDING 200, SUITE 220
KENNESAW GA
30144
US

V. Phone/Fax

Practice location:
  • Phone: 770-794-6643
  • Fax: 770-794-6683
Mailing address:
  • Phone: 770-794-6643
  • Fax: 770-794-6683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number058734
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number58734
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: