Basic Information
| Provider Information | |||||||||
| NPI: | 1700013216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST FRANCIS PHYSICIAN SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | WOODWARD MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743294 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642424122 | ||||||||
| FaxNumber: | 8642425867 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 SOUTH LEWIS PLAZA | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642424122 | ||||||||
| FaxNumber: | 8778933769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2009 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GAY | ||||||||
| AuthorizedOfficialFirstName: | WILBUR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8642551904 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST FRANCIS PHYSICIAN SERVICES INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RR0500X | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207R00000X | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP5272 | 05 | SC | MEDICAID |