Basic Information
| Provider Information | |||||||||
| NPI: | 1770516569 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEXINGTON COUNTY HEALTH SERVICES DISTRICT, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEXINGTON FAMILY PRACTICE IRMO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 470 HULON LN | ||||||||
| Address2: | ATTN: VP REVENUE CYCLE | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291694841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037912000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7037 ST ANDREWS ROAD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037320963 | ||||||||
| FaxNumber: | 8037321406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 01/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | KRUZNER | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8037912000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LEXINGTON COUNTY HEALTH SERVICES DISTRICT, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP2392 | 05 | SC | MEDICAID |