Provider Demographics
NPI:1396969002
Name:LAKE CITY FAMILY MEDICINE LLC
Entity type:Organization
Organization Name:LAKE CITY FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:843-374-8380
Mailing Address - Street 1:901 N. MATTHEWS RD.
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560
Mailing Address - Country:US
Mailing Address - Phone:843-374-8380
Mailing Address - Fax:
Practice Address - Street 1:901 N. MATTHEWS RD.
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560
Practice Address - Country:US
Practice Address - Phone:843-374-8380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17100261QR1300X
SC261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC175OtherRURAL HEALTH CLINIC
SCGP4692Medicaid
SCGP4692Medicaid
SC428988Medicare Oscar/Certification
8771Medicare PIN