Provider Demographics
NPI:1225492168
Name:NEXTPHASEMD
Entity Type:Organization
Organization Name:NEXTPHASEMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:QUAYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-861-2726
Mailing Address - Street 1:PO BOX 1763
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1763
Mailing Address - Country:US
Mailing Address - Phone:843-861-2726
Mailing Address - Fax:843-536-4194
Practice Address - Street 1:107 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4113
Practice Address - Country:US
Practice Address - Phone:843-861-2726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22891261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC22891OtherSC STATE LICENSE
SC228916Medicaid
SCSC 2958B578OtherPTAN
SC228916Medicaid