Provider Demographics
NPI:1932695848
Name:MOUNTAIN LAUREL INTERNAL MEDICINE
Entity Type:Organization
Organization Name:MOUNTAIN LAUREL INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEBMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-722-5915
Mailing Address - Street 1:1510 BLUE RIDGE BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29672-6684
Mailing Address - Country:US
Mailing Address - Phone:864-722-5315
Mailing Address - Fax:
Practice Address - Street 1:1510 BLUE RIDGE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-6684
Practice Address - Country:US
Practice Address - Phone:864-722-5315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT30712Medicaid