Provider Demographics
NPI:1073171336
Name:PROACTIVE MD SC,P.A.
Entity Type:Organization
Organization Name:PROACTIVE MD SC,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP MEDICAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:KEMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-907-8412
Mailing Address - Street 1:10 CENTIMETERS DR
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-3278
Mailing Address - Country:US
Mailing Address - Phone:864-501-0751
Mailing Address - Fax:864-990-3834
Practice Address - Street 1:801 UNION ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-2734
Practice Address - Country:US
Practice Address - Phone:864-596-2872
Practice Address - Fax:864-336-2948
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROACTIVE MD SC, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty