Provider Demographics
NPI:1740402130
Name:ST PAUL'S MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:ST PAUL'S MEDICAL GROUP, INC
Other - Org Name:ST PAULS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:GAY
Authorized Official - Last Name:DELAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:843-889-8018
Mailing Address - Street 1:PO BOX 1355
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29449-1355
Mailing Address - Country:US
Mailing Address - Phone:843-889-8018
Mailing Address - Fax:843-889-9133
Practice Address - Street 1:7610 HIGHWAY 164
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:SC
Practice Address - Zip Code:29449
Practice Address - Country:US
Practice Address - Phone:843-889-8018
Practice Address - Fax:843-889-9133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC42D0968299OtherCLIA NUMBER
SCGP2603Medicaid
SC42D0968299OtherCLIA NUMBER