1700160157 NPI number — MACKEY FAMILY PRACTICE, PA

Table of content: (NPI 1700160157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700160157 NPI number — MACKEY FAMILY PRACTICE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MACKEY FAMILY PRACTICE, 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:
1700160157
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8351 CHARLOTTE HWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
INDIAN LAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29707-6552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-396-5368
Provider Business Mailing Address Fax Number:
803-396-5350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8351 CHARLOTTE HWY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
INDIAN LAND
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29707-6552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-396-5368
Provider Business Practice Location Address Fax Number:
803-396-5350
Provider Enumeration Date:
10/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SHEALY
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
803-285-7414

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RHC211 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com