1417952169 NPI number — MICHELE MANGUM M.D.

Table of content: MICHELE MANGUM M.D. (NPI 1417952169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417952169 NPI number — MICHELE MANGUM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANGUM
Provider First Name:
MICHELE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417952169
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 INDEPENDENCE PT
Provider Second Line Business Mailing Address:
SUITE 212
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29615-4545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-797-6044
Provider Business Mailing Address Fax Number:
864-797-6198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 GROVE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29605-4210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-455-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  200100262 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 11868 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 118688 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".