Provider Demographics
NPI:1477998094
Name:MD2U SOUTH CAROLINA LLC
Entity Type:Organization
Organization Name:MD2U SOUTH CAROLINA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CIO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:LATTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-416-1851
Mailing Address - Street 1:140 WHITTINGTON PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4930
Mailing Address - Country:US
Mailing Address - Phone:502-327-9100
Mailing Address - Fax:855-632-8329
Practice Address - Street 1:4000 FABER PLACE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8585
Practice Address - Country:US
Practice Address - Phone:502-327-9100
Practice Address - Fax:855-632-8329
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MD2U MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty