Provider Demographics
NPI:1407034127
Name:OCONEE PHYSICIAN PRACTICES
Entity Type:Organization
Organization Name:OCONEE PHYSICIAN PRACTICES
Other - Org Name:BETWEEN THE LAKES PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:G
Authorized Official - Last Name:HEDTKE
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:864-885-7673
Mailing Address - Street 1:123 LILA DOYLE DR
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29672-9495
Mailing Address - Country:US
Mailing Address - Phone:864-885-7989
Mailing Address - Fax:864-885-7945
Practice Address - Street 1:106 RAM CAT ALY
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-3244
Practice Address - Country:US
Practice Address - Phone:864-888-4445
Practice Address - Fax:864-888-4345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QR1300X363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty