Basic Information
| Provider Information | |||||||||
| NPI: | 1124134762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAYCRAFT PAYNE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRAYCRAFT | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3686 WHEELER RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309096520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069226300 | ||||||||
| FaxNumber: | 7069226303 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH AUGUSTA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298413350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032791030 | ||||||||
| FaxNumber: | 8032781344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 58048 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 30432 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102I081896 | 01 | GA | MEDICARE | OTHER | BC9569229 | 01 | DEA | OTHER | 058408 | 01 | GA | STATE OF GEORGIA LICENSE | OTHER | FP4836118 | 01 | SC | DEA SC | OTHER | 30432 | 01 | SC | SC MEDICAL LICENSE | OTHER | G58408 | 05 | SC | MEDICAID | 20-30432 | 01 | SC | SC CONTROLLED SUBSTANCES | OTHER | SC5305D839 | 01 | SC | MEDICARE | OTHER |