Basic Information
| Provider Information | |||||||||
| NPI: | 1821085366 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORENCE PODIATRY ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 W CHEVES ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295014448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436799090 | ||||||||
| FaxNumber: | 8436799080 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 W CHEVES ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295014448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436799090 | ||||||||
| FaxNumber: | 8436799080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 05/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | JACOBUS | ||||||||
| AuthorizedOfficialFirstName: | DWAYNE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8436799090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | GP9918 | 05 | SC | MEDICAID | PD5658 | 05 | SC | MEDICAID |