Provider Demographics
NPI:1972590073
Name:PIEDMONT URGENT CARE CENTER AT BAXTER VILLAGE LLC
Entity Type:Organization
Organization Name:PIEDMONT URGENT CARE CENTER AT BAXTER VILLAGE LLC
Other - Org Name:BAXTER VILLAGE URGENT CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-2030
Mailing Address - Street 1:P.O. BOX 741327
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1327
Mailing Address - Country:US
Mailing Address - Phone:803-396-8100
Mailing Address - Fax:803-396-8040
Practice Address - Street 1:502 SIXTH BAXTER CROSSING
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6428
Practice Address - Country:US
Practice Address - Phone:803-396-8100
Practice Address - Fax:803-396-8040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3889Medicaid
CK6975Medicare PIN
SCGP3889Medicaid