Provider Demographics
NPI:1235364282
Name:LIVE OAK MEDICAL CENTER, PA
Entity Type:Organization
Organization Name:LIVE OAK MEDICAL CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:DURANT
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-687-0435
Mailing Address - Street 1:342 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-3235
Mailing Address - Country:US
Mailing Address - Phone:843-687-0435
Mailing Address - Fax:
Practice Address - Street 1:342 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-3235
Practice Address - Country:US
Practice Address - Phone:843-355-3621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVE OAK MEDICAL CENTER, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-20
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty