1558405563 NPI number — JAMES RUDOLPH MAHANES M.D.

Table of content: JAMES RUDOLPH MAHANES M.D. (NPI 1558405563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558405563 NPI number — JAMES RUDOLPH MAHANES M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHANES
Provider First Name:
JAMES
Provider Middle Name:
RUDOLPH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1558405563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 919
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:
29671-0919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-897-8280
Provider Business Mailing Address Fax Number:
864-897-8281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 WG ACKER DRIVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
PICKENS
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-898-1360
Provider Business Practice Location Address Fax Number:
864-898-1037
Provider Enumeration Date:
02/16/2007

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: 208600000X , with the licence number:  6957 , 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: GP4587 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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