1821073875 NPI number — TONY SAMUEL POTEAT JR. MD

Table of content: TONY SAMUEL POTEAT JR. MD (NPI 1821073875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821073875 NPI number — TONY SAMUEL POTEAT JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTEAT
Provider First Name:
TONY
Provider Middle Name:
SAMUEL
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
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:
1821073875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2012
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:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 VERDAE BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29607-4032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-242-4683
Provider Business Practice Location Address Fax Number:
864-240-8104
Provider Enumeration Date:
12/13/2005

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: 207R00000X , with the licence number:  20978 , 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: 110186538 . This is a "RR MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: T51217 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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