Healthcare Provider Details

I. General information

NPI: 1861502890
Provider Name (Legal Business Name): GOOD SHEPHERD FAMILY PRACTICE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N EARLE ST
WALHALLA SC
29691-2419
US

IV. Provider business mailing address

235 SCENIC HEIGHTS RD
WEST UNION SC
29696-3134
US

V. Phone/Fax

Practice location:
  • Phone: 864-614-2182
  • Fax: 864-718-5354
Mailing address:
  • Phone: 864-614-2182
  • Fax: 864-718-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15666
License Number StateSC

VIII. Authorized Official

Name: DR. JAMES W. N. COCHRAN
Title or Position: OWNER
Credential: MD
Phone: 864-614-2182