Provider Demographics
NPI:1336475268
Name:LAKE CITY ORTHOPAEDIC CLINIC
Entity Type:Organization
Organization Name:LAKE CITY ORTHOPAEDIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-374-6431
Mailing Address - Street 1:PO BOX 1479
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-1479
Mailing Address - Country:US
Mailing Address - Phone:843-374-5267
Mailing Address - Fax:843-374-6243
Practice Address - Street 1:330 MERCY ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2332
Practice Address - Country:US
Practice Address - Phone:843-374-5267
Practice Address - Fax:843-374-6243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC400667Medicaid
SCB91527Medicare UPIN