Basic Information
| Provider Information | |||||||||
| NPI: | 1407034127 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OCONEE PHYSICIAN PRACTICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BETWEEN THE LAKES PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 123 LILA DOYLE DR | ||||||||
| Address2: | |||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296729495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648857989 | ||||||||
| FaxNumber: | 8648857945 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 RAM CAT ALY | ||||||||
| Address2: | |||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296783244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648884445 | ||||||||
| FaxNumber: | 8648884345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2008 | ||||||||
| LastUpdateDate: | 02/05/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEDTKE | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8648857673 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 261QR1300X | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.