Basic Information
| Provider Information | |||||||||
| NPI: | 1073564027 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH BERKELEY FAMILY CARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 280 | ||||||||
| Address2: | 137 CEDAR DR | ||||||||
| City: | SAINT STEPHEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294790280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435674000 | ||||||||
| FaxNumber: | 8435673000 | ||||||||
| Practice Location | |||||||||
| Address1: | 137 CEDAR DR | ||||||||
| Address2: | |||||||||
| City: | SAINT STEPHEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294793371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435674000 | ||||||||
| FaxNumber: | 8435673000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | HOLLEMAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8435674000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QP2300X | 17261 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1982791414 | 01 | SC | NPI# FOR PA-C EMPLOYED | OTHER | GP4402 | 05 | SC | MEDICAID | 1407852791 | 01 | SC | NPI # FOR MD EMPLOYED | OTHER |