Provider Demographics
NPI:1962656892
Name:ST FRANCIS PHYSICIAN SERVICES INC
Entity Type:Organization
Organization Name:ST FRANCIS PHYSICIAN SERVICES INC
Other - Org Name:INTERNAL MEDICINE AND DIAGNOSTIC GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILBUR
Authorized Official - Middle Name:R
Authorized Official - Last Name:GAY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:864-605-3762
Mailing Address - Street 1:PO BOX 743294
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3294
Mailing Address - Country:US
Mailing Address - Phone:864-295-1750
Mailing Address - Fax:864-295-1753
Practice Address - Street 1:2 INNOVATION DR.
Practice Address - Street 2:SUITE 140
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5263
Practice Address - Country:US
Practice Address - Phone:864-295-1750
Practice Address - Fax:864-295-1753
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST FRANCIS PHYSICIAN SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-05
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
SC207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5049Medicaid
SCGP5049Medicaid
SC8157Medicare PIN