MEDICARE: PIEDMONT FAMILY PRACTICE AT BAXTER VILLAGE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1548695232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIEDMONT FAMILY PRACTICE AT BAXTER VILLAGE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 742746
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-2746
Country	:	US
Telephone Number	:	803-835-2088
Fax Number	:	803-835-2099

Provider Business Practice Location Address
First Line	:	502 SIXTH BAXTER XING
Second Line	:	STE A
City	:	FORT MILL
State	:	SC
Zip	:	29708-6428
Country	:	US
Telephone Number	:	803-835-2088
Fax Number	:	803-835-2099

Authorized Official
Title or Position	:	REGIONAL CFO, TENET
Name	:	MR. WESLEY O. JAMES
Credential	:
Telephone Number	:	404-265-5009

Provider Enumeration Date	:	09/12/2013
Last Update Date	:	06/23/2016

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