Provider Demographics
NPI:1740590157
Name:FOREST DRIVE PHYSICIANS
Entity Type:Organization
Organization Name:FOREST DRIVE PHYSICIANS
Other - Org Name:DOCTORS EXPRESS COLUMBIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEAD PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:LORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-386-6374
Mailing Address - Street 1:PO BOX 290192
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-0004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3304 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4024
Practice Address - Country:US
Practice Address - Phone:803-386-6374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC257420Medicaid
SC257420Medicaid
SC122753Medicare UPIN