Healthcare Provider Details

I. General information

NPI: 1790216505
Provider Name (Legal Business Name): BENJAMIN GREGORY CRISP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 LAKE BOONE TRL STE 210
RALEIGH NC
27607-6685
US

IV. Provider business mailing address

4207 LAKE BOONE TRL STE 210
RALEIGH NC
27607-6685
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-7874
  • Fax: 919-784-2708
Mailing address:
  • Phone: 919-784-7874
  • Fax: 919-784-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number332669
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2023-02063
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: