Provider Demographics
NPI:1083814438
Name:OAKTREE MEDICAL CENTRE, PC
Entity Type:Organization
Organization Name:OAKTREE MEDICAL CENTRE, PC
Other - Org Name:PAIN MANAGENENT ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-855-1633
Mailing Address - Street 1:PO BOX 484
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-0484
Mailing Address - Country:US
Mailing Address - Phone:864-855-1633
Mailing Address - Fax:864-855-1323
Practice Address - Street 1:1005 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4630
Practice Address - Country:US
Practice Address - Phone:864-404-3096
Practice Address - Fax:864-404-3183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2763Medicaid
SCGP2763Medicaid