Provider Demographics
NPI:1275647885
Name:CENTER FOR ADULT AND FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:CENTER FOR ADULT AND FAMILY MEDICINE PA
Other - Org Name:CENTER FOR ADULT MEDICINE, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:RICHTER
Authorized Official - Suffix:
Authorized Official - Credentials:NA
Authorized Official - Phone:864-627-1220
Mailing Address - Street 1:317 SAINT FRANCIS DR
Mailing Address - Street 2:SUITE 360
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-3965
Mailing Address - Country:US
Mailing Address - Phone:864-627-1220
Mailing Address - Fax:864-627-1221
Practice Address - Street 1:317 SAINT FRANCIS DR
Practice Address - Street 2:SUITE 360
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3965
Practice Address - Country:US
Practice Address - Phone:864-627-1220
Practice Address - Fax:864-627-1221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22970207Q00000X
SC17244207R00000X
SC21280207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8600Medicare PIN
SC8157Medicare PIN