1326074576 NPI number — WELL FAMILY MEDICINE

Table of content: (NPI 1326074576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326074576 NPI number — WELL FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELL FAMILY MEDICINE
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:
1326074576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1483 TOBIAS GADSON BLVD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29407-8702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-766-6229
Provider Business Mailing Address Fax Number:
843-766-2315

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1483 TOBIAS GADSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29407-8702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-766-6229
Provider Business Practice Location Address Fax Number:
843-766-2315
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COX
Authorized Official First Name:
LORI
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
843-766-6229

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  19704 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 19704 , 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: 197049 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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