Basic Information
Provider Information | |||||||||
NPI: | 1831375856 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OCONEE PHYSICIAN PRACTICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UPSTATE FAMILY MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301 MEMORIAL DR STE G | ||||||||
Address2: |   | ||||||||
City: | SENECA | ||||||||
State: | SC | ||||||||
PostalCode: | 296729445 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8648857989 | ||||||||
FaxNumber: | 8648857945 | ||||||||
Practice Location | |||||||||
Address1: | 109 OMNI DR | ||||||||
Address2: |   | ||||||||
City: | SENECA | ||||||||
State: | SC | ||||||||
PostalCode: | 296729448 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8648826141 | ||||||||
FaxNumber: | 8648826680 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/22/2008 | ||||||||
LastUpdateDate: | 01/22/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HEDTKE | ||||||||
AuthorizedOfficialFirstName: | MATTHEW | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8648857989 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   | SC | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | GP4697 | 05 | SC |   | MEDICAID |