Healthcare Provider Details

I. General information

NPI: 1871827790
Provider Name (Legal Business Name): EMMAUS MED/SURG CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 E MAIN ST SUITE C
LEXINGTON SC
29072-3729
US

IV. Provider business mailing address

602 E MAIN ST SUITE C
LEXINGTON SC
29072-3729
US

V. Phone/Fax

Practice location:
  • Phone: 803-359-0164
  • Fax: 803-359-0255
Mailing address:
  • Phone: 803-359-0164
  • Fax: 803-359-0255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number30244
License Number StateSC

VIII. Authorized Official

Name: DR. BERT B OUBRE
Title or Position: OWNER
Credential: MD
Phone: 803-359-0164