Provider Demographics
NPI:1003831645
Name:TWELVE MILE CREEK FAMILY MEDICINE
Entity Type:Organization
Organization Name:TWELVE MILE CREEK FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:O
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:803-356-3609
Mailing Address - Street 1:4711 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9151
Mailing Address - Country:US
Mailing Address - Phone:803-356-3609
Mailing Address - Fax:803-356-3941
Practice Address - Street 1:4711 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9151
Practice Address - Country:US
Practice Address - Phone:803-356-3609
Practice Address - Fax:803-356-3941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6661Medicare PIN