Basic Information
Provider Information | |||||||||
NPI: | 1588690382 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GROW | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CRAWFORD | ||||||||
OtherFirstName: | KELLY | ||||||||
OtherMiddleName: | B | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1001 SUMMIT BLVD STE 200 | ||||||||
Address2: |   | ||||||||
City: | BROOKHAVEN | ||||||||
State: | GA | ||||||||
PostalCode: | 303196410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709891668 | ||||||||
FaxNumber: | 7063699673 | ||||||||
Practice Location | |||||||||
Address1: | 340 N MILLEDGE AVE STE B | ||||||||
Address2: |   | ||||||||
City: | ATHENS | ||||||||
State: | GA | ||||||||
PostalCode: | 306013806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7065480008 | ||||||||
FaxNumber: | 7063699673 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2006 | ||||||||
LastUpdateDate: | 10/03/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 051353 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 382474810H | 05 | GA |   | MEDICAID |