1902232168 NPI number — MEDICAL HOME DEVELOPMENT GROUP

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 1902232168 NPI number — MEDICAL HOME DEVELOPMENT GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL HOME DEVELOPMENT GROUP
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:
1902232168
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4975 LACROSS RD
Provider Second Line Business Mailing Address:
SUITE 153
Provider Business Mailing Address City Name:
N CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29406-6523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-412-5548
Provider Business Mailing Address Fax Number:
866-643-9237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1647 BENNING RD NE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20002-4569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-412-5548
Provider Business Practice Location Address Fax Number:
866-643-9237
Provider Enumeration Date:
09/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WHETSELL
Authorized Official First Name:
AUDREY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
843-412-5548

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  SCLN12893 , 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)





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