Provider Demographics
NPI:1720092505
Name:PIEDMONT INTERNAL MEDICINE AT BAXTER VILLAGE LLC
Entity Type:Organization
Organization Name:PIEDMONT INTERNAL MEDICINE AT BAXTER VILLAGE LLC
Other - Org Name:BAXTER INTERNAL MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:J.
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-6960
Mailing Address - Street 1:PO BOX 741344
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1344
Mailing Address - Country:US
Mailing Address - Phone:803-802-2424
Mailing Address - Fax:803-802-3767
Practice Address - Street 1:502 SIXTH BAXTER CROSSING
Practice Address - Street 2:SUITE A
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708
Practice Address - Country:US
Practice Address - Phone:803-802-2424
Practice Address - Fax:803-802-3767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4469Medicaid
SCGP4469Medicaid
SCDN9293Medicare PIN