Provider Demographics
NPI:1184083982
Name:POWDERSVILLE HEALTH INTERNAL MEDICINE
Entity type:Organization
Organization Name:POWDERSVILLE HEALTH INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:MCNEELY
Authorized Official - Last Name:LOLLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-568-5018
Mailing Address - Street 1:3150 HIGHWAY 153
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SC
Mailing Address - Zip Code:29673-9498
Mailing Address - Country:US
Mailing Address - Phone:864-568-5018
Mailing Address - Fax:864-295-0095
Practice Address - Street 1:3150 HIGHWAY 153
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:SC
Practice Address - Zip Code:29673-9498
Practice Address - Country:US
Practice Address - Phone:864-568-5018
Practice Address - Fax:864-295-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD38594261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC385942Medicaid