Provider Demographics
NPI:1932652856
Name:MEDPRIMARY LLC
Entity Type:Organization
Organization Name:MEDPRIMARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:V
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD, CPE, CEO
Authorized Official - Phone:843-619-2990
Mailing Address - Street 1:1327 DEEP WATER DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103B HARTH PL
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8107
Practice Address - Country:US
Practice Address - Phone:843-619-2990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23088207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty