Provider Demographics
NPI:1235773979
Name:PROACTIVE MD,SC,P.A.
Entity Type:Organization
Organization Name:PROACTIVE MD,SC,P.A.
Other - Org Name:PROACTIVE MD MAULDIN HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOC. OPS MGR
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-501-0751
Mailing Address - Street 1:124 ALLAWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6207
Mailing Address - Country:US
Mailing Address - Phone:864-501-0751
Mailing Address - Fax:
Practice Address - Street 1:787 E BUTLER RD STE B
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-3276
Practice Address - Country:US
Practice Address - Phone:864-501-0751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROACTIVE MD,SC,P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-06
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty