Provider Demographics
NPI:1770030926
Name:HARTSVILLE MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:HARTSVILLE MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:YOLANDA
Authorized Official - Last Name:MENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-683-3793
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-0247
Mailing Address - Country:US
Mailing Address - Phone:843-917-4117
Mailing Address - Fax:
Practice Address - Street 1:206 SWIFT CREEK RD
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4383
Practice Address - Country:US
Practice Address - Phone:843-917-4117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-06
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7551Medicaid
SC12769293OtherPROVIDER PTAN
SC1609197623OtherNPI
SC12769293OtherPROVIDER PTAN