Healthcare Provider Details

I. General information

NPI: 1831203918
Provider Name (Legal Business Name): MILL STREET MEDICAL ASSOCIATES, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 MILL ST
CAMDEN SC
29020-3763
US

IV. Provider business mailing address

1113 MILL ST
CAMDEN SC
29020-3763
US

V. Phone/Fax

Practice location:
  • Phone: 803-432-3379
  • Fax:
Mailing address:
  • Phone: 803-432-3379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15151
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number3592
License Number StateSC

VIII. Authorized Official

Name: KAREN H LANE
Title or Position: BILLING
Credential:
Phone: 803-432-3379