1104812692 NPI number — FLEETWOOD INTERNAL MEDICINE PA

Table of content: (NPI 1104812692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104812692 NPI number — FLEETWOOD INTERNAL MEDICINE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLEETWOOD INTERNAL MEDICINE PA
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:
1104812692
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 309
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PICKENS
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29671-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-850-1441
Provider Business Mailing Address Fax Number:
864-850-1482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109B FLEETWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EASLEY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29640-2019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-855-1036
Provider Business Practice Location Address Fax Number:
864-855-3318
Provider Enumeration Date:
09/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
STROUD
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
864-855-1036

Provider Taxonomy Codes

  • Taxonomy code: 207QA0401X , with the licence number:  8878 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 9099 , 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: 851 , 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: PA4726 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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