Basic Information
| Provider Information | |||||||||
| NPI: | 1134418296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAIG | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | SUTTON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SUTTON | ||||||||
| OtherFirstName: | MEGAN | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3240 AVALON BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708601133 | ||||||||
| FaxNumber: | 7708601599 | ||||||||
| Practice Location | |||||||||
| Address1: | 3240 AVALON BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708601133 | ||||||||
| FaxNumber: | 7708601599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2011 | ||||||||
| LastUpdateDate: | 10/14/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 073697 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 003159162B | 05 | GA | MEDICAID |