Basic Information
| Provider Information | |||||||||
| NPI: | 1073171336 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROACTIVE MD SC,P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 CENTIMETERS DR | ||||||||
| Address2: | |||||||||
| City: | MAULDIN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296623278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
| FaxNumber: | 8649903834 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 UNION ST | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293022734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645962872 | ||||||||
| FaxNumber: | 8643362948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2019 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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| AuthorizedOfficialLastName: | KEMBLE | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP MEDICAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 8649078412 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROACTIVE MD SC, P.A. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.