Provider Demographics
NPI:1831203918
Name:MILL STREET MEDICAL ASSOCIATES, LLP
Entity type:Organization
Organization Name:MILL STREET MEDICAL ASSOCIATES, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:H
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-432-3379
Mailing Address - Street 1:1113 MILL ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-3763
Mailing Address - Country:US
Mailing Address - Phone:803-432-3379
Mailing Address - Fax:
Practice Address - Street 1:1113 MILL ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-3763
Practice Address - Country:US
Practice Address - Phone:803-432-3379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3592207R00000X
SC15151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4375Medicaid
SC8474Medicare PIN