Provider Demographics
NPI:1407863343
Name:PIEDMONT FAMILY PRACTICE AT TEGA CAY, LLC
Entity Type:Organization
Organization Name:PIEDMONT FAMILY PRACTICE AT TEGA CAY, LLC
Other - Org Name:PIEDMONT FAMILY PRACTICE AT TEGA CAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL CFO, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:O
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-265-5009
Mailing Address - Street 1:773 STOCKBRIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708
Mailing Address - Country:US
Mailing Address - Phone:803-802-2424
Mailing Address - Fax:803-802-3767
Practice Address - Street 1:773 STOCKBRIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708
Practice Address - Country:US
Practice Address - Phone:803-802-2424
Practice Address - Fax:803-802-3767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4723Medicaid
SCDO0992OtherRAILROAD MEDICARE PTAN NUMBER
SCGP4723Medicaid