Provider Demographics
NPI:1649647884
Name:GATEWAY MEDICAL LLC
Entity type:Organization
Organization Name:GATEWAY MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JEFFCOAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-957-0500
Mailing Address - Street 1:PO BOX 2169
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29071-2169
Mailing Address - Country:US
Mailing Address - Phone:803-358-6762
Mailing Address - Fax:803-358-1708
Practice Address - Street 1:171B MONROE LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-3904
Practice Address - Country:US
Practice Address - Phone:803-358-8496
Practice Address - Fax:866-614-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7520Medicaid