Basic Information
| Provider Information | |||||||||
| NPI: | 1659816932 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROACTIVE MD SC,P.A. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROACTIVE MD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 CENTIMETERS DR | ||||||||
| Address2: | |||||||||
| City: | MAULDIN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296623278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
| FaxNumber: | 8649005476 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 CENTIMETERS DR | ||||||||
| Address2: | |||||||||
| City: | MAULDIN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296623278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
| FaxNumber: | 8649005476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2016 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEMBLE | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF CLINICAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 8649078412 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.