Basic Information
| Provider Information | |||||||||
| NPI: | 1811017635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAMER | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | TUCCI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TUCCI | ||||||||
| OtherFirstName: | MONICA | ||||||||
| OtherMiddleName: | CATHLEEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 RICHLAND MEDICAL PARK DR | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034343572 | ||||||||
| FaxNumber: | 8034348606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 1016 | AL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | DO1038 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0210X | DO1038 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 010428 | 05 | SC | MEDICAID |