Provider Demographics
NPI:1861502890
Name:GOOD SHEPHERD FAMILY PRACTICE, PA
Entity Type:Organization
Organization Name:GOOD SHEPHERD FAMILY PRACTICE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W N
Authorized Official - Last Name:COCHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-614-2182
Mailing Address - Street 1:235 SCENIC HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:SC
Mailing Address - Zip Code:29696-3134
Mailing Address - Country:US
Mailing Address - Phone:864-614-2182
Mailing Address - Fax:864-718-5354
Practice Address - Street 1:111 N EARLE ST
Practice Address - Street 2:
Practice Address - City:WALHALLA
Practice Address - State:SC
Practice Address - Zip Code:29691-2419
Practice Address - Country:US
Practice Address - Phone:864-614-2182
Practice Address - Fax:864-718-5354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15666207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC156663Medicaid
SC156663Medicaid
SCE96841Medicare UPIN