Basic Information
| Provider Information | |||||||||
| NPI: | 1164429825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRISTENSEN | ||||||||
| FirstName: | TOM | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | AGAPE SENIOR PRIMARY CARE INC DBA MAIN STREET PHYSICIAN | ||||||||
| Address2: | 1624 MAIN STREET | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037262350 | ||||||||
| FaxNumber: | 8037539102 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 SEA MOUNTAIN HIGWAY | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LITTLE RIVER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433994848 | ||||||||
| FaxNumber: | 9106532346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 18363 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5950176 | 05 | NC | MEDICAID | 5950653 | 05 | NC | MEDICAID | 0248H | 01 | NC | NC BCBS | OTHER | 02787 | 01 | NC | NC BCBS | OTHER | 561243962 | 01 | SC | BCBS | OTHER | 080076269 | 01 | NC | RAILROAD MEDICARE | OTHER | 4770 | 01 | SC | SC MEDICARE | OTHER | 2315069 | 01 | NC | CIGNA MEDICARE | OTHER | E03PA0 | 05 | SC | MEDICAID | 0363 | 01 | NC | CIGNA MEDICARE | OTHER | 570941629 | 01 | SC | BCBS | OTHER | 561833405 | 01 | SC | SC BCBS | OTHER | GP1062 | 05 | SC | MEDICAID | NPA648 | 05 | SC | MEDICAID |