Basic Information
| Provider Information | |||||||||
| NPI: | 1184746158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUDGINGTON | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CAY | ||||||||
| OtherFirstName: | RACHEL | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705334786 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 JESSE JEWELL PKWY SE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705353611 | ||||||||
| FaxNumber: | 7705357092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 060718 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 178218352D | 05 | GA | MEDICAID | 9806158 | 01 | GA | AETNA | OTHER | 178218352C | 05 | GA | MEDICAID | 453425 | 01 | GA | WELLCARE | OTHER | 52245265 | 01 | GA | BCBS | OTHER | 582117020018 | 01 | GA | TRICARE | OTHER | 01184316 | 01 | GA | AMERIGROUP | OTHER | 453415 | 01 | GA | WELLCARE | OTHER | 582117020 | 01 | GA | TRICARE | OTHER | 582117020024 | 01 | GA | TRICARE | OTHER | 453382 | 01 | GA | WELLCARE | OTHER | 8974812 | 01 | GA | CIGNA | OTHER | 178218352E | 05 | GA | MEDICAID | 178218352A | 05 | GA | MEDICAID | 178218352B | 05 | GA | MEDICAID | 530894 | 01 | GA | WELLCARE | OTHER | 453429 | 01 | GA | WELLCARE | OTHER | 582117020030 | 01 | GA | TRICARE | OTHER |