Basic Information
| Provider Information | |||||||||
| NPI: | 1619921905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRABBE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | MACGREGOR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 N SUMTER ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291504972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037754655 | ||||||||
| FaxNumber: | 8037757258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 15833 | SC | N | Other Service Providers | Specialist | 208600000X | 15833 | SC | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 15833 | SC | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 158331 | 05 | SC | MEDICAID |