Basic Information
| Provider Information | |||||||||
| NPI: | 1477998094 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MD2U SOUTH CAROLINA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 WHITTINGTON PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402224930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023279100 | ||||||||
| FaxNumber: | 8556328329 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 FABER PLACE DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294058585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023279100 | ||||||||
| FaxNumber: | 8556328329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2013 | ||||||||
| LastUpdateDate: | 05/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | LATTA | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CIO | ||||||||
| AuthorizedOfficialTelephone: | 5024161851 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MD2U MANAGEMENT LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.