1265489025 NPI number — DR. MARTHA DESCHAMPS PETOSKEY PH.D.

Table of content: PETER C SCHALOCK M.D. (NPI 1265490866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265489025 NPI number — DR. MARTHA DESCHAMPS PETOSKEY PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETOSKEY
Provider First Name:
MARTHA
Provider Middle Name:
DESCHAMPS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.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:
1265489025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 WILLING LAKES CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGEBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29118-1861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-384-9002
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
261 GREENGATE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29307-2211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-494-0928
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/27/2006

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: 103TS0200X , with the licence number:  881 , 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: WP8965 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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