Basic Information
| Provider Information | |||||||||
| NPI: | 1477931236 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCAW | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | JHEANELLE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 WESTVIEW DRIVE, SW | ||||||||
| Address2: | MOREHOUSE SCHOOL OF MEDICINE, DEPARTMENT OF INTERNAL ME | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047561325 | ||||||||
| FaxNumber: | 4047561313 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 WESTVIEW DRIVE, SW | ||||||||
| Address2: | MOREHOUSE SCHOOL OF MEDICINE, DEPARTMENT OF INTERNAL ME | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047561325 | ||||||||
| FaxNumber: | 4047561313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2015 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/21/2015 | ||||||||
| NPIReactivationDate: | 12/29/2015 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 079271 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.