Provider Demographics
NPI:1750843132
Name:PROACTIVE MD SC,P.A.
Entity Type:Organization
Organization Name:PROACTIVE MD SC,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP OF MEDICAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:KEMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-501-0751
Mailing Address - Street 1:10 CENTIMETERS DR
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-3278
Mailing Address - Country:US
Mailing Address - Phone:864-501-0751
Mailing Address - Fax:
Practice Address - Street 1:245 PARKWAY E
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-9489
Practice Address - Country:US
Practice Address - Phone:864-501-0751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-03
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty