Healthcare Provider Details

I. General information

NPI: 1215156112
Provider Name (Legal Business Name): GRANITEVILLE FAMILY MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HICKMAN ST
GRANITEVILLE SC
29829-2955
US

IV. Provider business mailing address

1 HICKMAN ST
GRANITEVILLE SC
29829-2955
US

V. Phone/Fax

Practice location:
  • Phone: 803-663-9224
  • Fax: 803-663-8893
Mailing address:
  • Phone: 803-663-9224
  • Fax: 803-663-8893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27455
License Number StateSC

VIII. Authorized Official

Name: DR. MAE JEAN ENGLEE
Title or Position: PHYSICIAN
Credential: MD
Phone: 803-663-9224