Basic Information
| Provider Information | |||||||||
| NPI: | 1144467960 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE CITY FAMILY MEDICINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 N MATTHEWS RD | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295607024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433748380 | ||||||||
| FaxNumber: | 8433745247 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 N MATTHEWS RD | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295607024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433748380 | ||||||||
| FaxNumber: | 8433745247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2009 | ||||||||
| LastUpdateDate: | 01/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | MORRIS | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8433748380 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | RHC175 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHC175 | 05 | SC | MEDICAID |