=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427296565
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLSPRINGS MEDICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2009
-----------------------------------------------------
Last Update Date | 01/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 NE MAIN ST
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681-2318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-963-7070
-----------------------------------------------------
Fax | 864-963-5770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 224 NE MAIN ST
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681-2318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-963-7070
-----------------------------------------------------
Fax | 864-963-5770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | JOSHUA PAUL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 864-963-7070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 20084
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------