Basic Information
| Provider Information | |||||||||
| NPI: | 1659506699 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIVE OAK MEDICAL CENTER, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 SAULS ST. | ||||||||
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| City: | LAKE CITY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433743621 | ||||||||
| FaxNumber: | 8433743624 | ||||||||
| Practice Location | |||||||||
| Address1: | 148 SAULS ST. | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436870435 | ||||||||
| FaxNumber: | 8433743624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2009 | ||||||||
| LastUpdateDate: | 01/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | MIMS | ||||||||
| AuthorizedOfficialFirstName: | ALBERT | ||||||||
| AuthorizedOfficialMiddleName: | DURANT | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8433743621 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9352 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP5322 | 05 | SC | MEDICAID |