Provider Demographics
NPI:1265508550
Name:DUE WEST FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:DUE WEST FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-379-2345
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:DUE WEST
Mailing Address - State:SC
Mailing Address - Zip Code:29639-0638
Mailing Address - Country:US
Mailing Address - Phone:864-379-2345
Mailing Address - Fax:864-379-3228
Practice Address - Street 1:6 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:DUE WEST
Practice Address - State:SC
Practice Address - Zip Code:29639
Practice Address - Country:US
Practice Address - Phone:864-379-2345
Practice Address - Fax:864-379-3228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC074Medicaid
SC428905Medicare Oscar/Certification