Provider Demographics
NPI:1356397558
Name:MEDLOCK, MELVIN (MD)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:
Last Name:MEDLOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 DILLON DRIVE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307
Practice Address - Country:US
Practice Address - Phone:864-585-2027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4226207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC042260Medicaid
GAP00386799OtherMEDICARE RAILROAD PTAN#
SC8688Medicare PIN
SCB92202Medicare ID - Type Unspecified
GAP00386799OtherMEDICARE RAILROAD PTAN#
SC042260Medicaid