Provider Demographics
NPI:1538235817
Name:MCCRACKEN, MARK S (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:MCCRACKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1499 FAIR RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-1683
Mailing Address - Country:US
Mailing Address - Phone:912-839-2810
Mailing Address - Fax:912-839-2808
Practice Address - Street 1:1499 FAIR RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1683
Practice Address - Country:US
Practice Address - Phone:912-486-1430
Practice Address - Fax:912-871-2262
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA055863207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA391955373AMedicaid
GAI29694Medicare UPIN
GA11SCDZNMedicare ID - Type Unspecified