Provider Demographics
NPI:1588835243
Name:MAULDIN MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:MAULDIN MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NAKEIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHARTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-236-9555
Mailing Address - Street 1:545 W BUTLER RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4833
Mailing Address - Country:US
Mailing Address - Phone:864-236-9555
Mailing Address - Fax:864-236-9551
Practice Address - Street 1:3443 PELHAM RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4178
Practice Address - Country:US
Practice Address - Phone:864-236-9555
Practice Address - Fax:864-234-9029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3769Medicaid
SC7761Medicare PIN