Basic Information
Provider Information | |||||||||
NPI: | 1780926675 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OCONEE PHYSICIAN PRACTICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BETWEEN THE LAKES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 601082 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282601082 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8648857989 | ||||||||
FaxNumber: | 8648857642 | ||||||||
Practice Location | |||||||||
Address1: | 106 RAM CAT ALY | ||||||||
Address2: |   | ||||||||
City: | SENECA | ||||||||
State: | SC | ||||||||
PostalCode: | 296783244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8648884445 | ||||||||
FaxNumber: | 8648884345 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2013 | ||||||||
LastUpdateDate: | 03/19/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WOOD | ||||||||
AuthorizedOfficialFirstName: | EARL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 8648884445 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 1908 | SC | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.