Basic Information
Provider Information
NPI: 1083815799
EntityType: 2
ReplacementNPI:  
OrganizationName: LOWER FLORENCE COUNTY HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: PEE DEE FAMILY PRACTICE JOHNSONVILLE
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 258 N RON MCNAIR BLVD
Address2:  
City: LAKE CITY
State: SC
PostalCode: 295602462
CountryCode: US
TelephoneNumber: 8433742036
FaxNumber: 8433745315
Practice Location
Address1: 625 S GEORGETOWN HWY
Address2:  
City: JOHNSONVILLE
State: SC
PostalCode: 29555
CountryCode: US
TelephoneNumber: 8433862350
FaxNumber: 8433863791
Other Information
ProviderEnumerationDate: 05/30/2007
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: DUKE
AuthorizedOfficialFirstName: MARY
AuthorizedOfficialMiddleName: C
AuthorizedOfficialTitleorPosition: DIRECTOR OF PFS
AuthorizedOfficialTelephone: 8433746431
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XGP2834SCY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
GP283405SC MEDICAID


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