Provider Demographics
NPI:1366834640
Name:DORN MEDICAL GROUP, P.A.
Entity Type:Organization
Organization Name:DORN MEDICAL GROUP, P.A.
Other - Org Name:BLYTHEWOOD URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:E
Authorized Official - Last Name:DORN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:803-606-8935
Mailing Address - Street 1:220 LAKE ESTATE DR
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-7789
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 BLYTHEWOOD RD
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-8426
Practice Address - Country:US
Practice Address - Phone:803-606-8935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05553261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care