Provider Demographics
NPI:1578650792
Name:INTERNAL MEDICINE & DIAGNOSTICS GROUP
Entity Type:Organization
Organization Name:INTERNAL MEDICINE & DIAGNOSTICS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LELAND
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:864-295-1750
Mailing Address - Street 1:17 MEMORIAL MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4407
Mailing Address - Country:US
Mailing Address - Phone:864-295-1750
Mailing Address - Fax:864-295-1753
Practice Address - Street 1:17 MEMORIAL MEDICAL DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4407
Practice Address - Country:US
Practice Address - Phone:864-295-1750
Practice Address - Fax:864-295-1753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7401261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3968Medicare PIN