1063408979 NPI number — MT PLEASANT FAMILY PRACTICE,PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063408979 NPI number — MT PLEASANT FAMILY PRACTICE,PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MT PLEASANT FAMILY PRACTICE,PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1063408979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 BOWMAN RD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
MT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29464-3203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-884-1341
Provider Business Mailing Address Fax Number:
843-884-1345

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 BOWMAN RD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
MT PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-3203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-884-1341
Provider Business Practice Location Address Fax Number:
843-884-1345
Provider Enumeration Date:
09/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
OWENS
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
ROGERS
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
843-884-1341

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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