Basic Information
| Provider Information | |||||||||
| NPI: | 1154594786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKELANDS ORTHOPAEDIC CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3243 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296463243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642292663 | ||||||||
| FaxNumber: | 8642235694 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 COMMERCIAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | ABBEVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296205593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8643668332 | ||||||||
| FaxNumber: | 8643660635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2008 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | POORE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 8643230527 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | GP3321 | 05 | SC | MEDICAID |