Basic Information
| Provider Information | |||||||||
| NPI: | 1356527352 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OCONEE PHYSICIAN PRACTICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BETWEEN THE LAKESPRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 301 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296729491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648857989 | ||||||||
| FaxNumber: | 8644457945 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 RAM CAT ALY | ||||||||
| Address2: | |||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296783244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648884445 | ||||||||
| FaxNumber: | 8648884345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2008 | ||||||||
| LastUpdateDate: | 01/21/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEDTKE | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8648857989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | GP4697 | 05 | SC | MEDICAID |