1780634824 NPI number — LUKE ANTHONY DOLAN MD

Table of content: LUKE ANTHONY DOLAN MD (NPI 1780634824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780634824 NPI number — LUKE ANTHONY DOLAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOLAN
Provider First Name:
LUKE
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1780634824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743294
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-3294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-963-8002
Provider Business Mailing Address Fax Number:
864-963-2742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
DOCTOR'S FAMILY MEDICINE
Provider Second Line Business Practice Location Address:
3115-D BRUSHY CREEK RD.
Provider Business Practice Location Address City Name:
GREER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29650-0903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-877-4221
Provider Business Practice Location Address Fax Number:
877-379-3003
Provider Enumeration Date:
05/11/2006

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: 207R00000X , with the licence number:  24784 , 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: 247842 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01089179 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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