Basic Information
| Provider Information | |||||||||
| NPI: | 1912107640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDCROSS | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE STE 130 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704280462 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE STE 130 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704280462 | ||||||||
| FaxNumber: | 7704278001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 11/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 1132 | SC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | OT 010413 | PA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 69941 | GA | Y | Allopathic & Osteopathic Physicians | Surgery | 202K00000X | 1132 | SC | N | Allopathic & Osteopathic Physicians | Phlebology |
ID Information
| ID | Type | State | Issuer | Description | GP3518 | 05 | SC | MEDICAID |