Provider Demographics
NPI:1063445971
Name:WELLNESS FAMILY MEDICINE
Entity type:Organization
Organization Name:WELLNESS FAMILY MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:EARLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:864-591-0992
Mailing Address - Street 1:1241 BOILING SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-2258
Mailing Address - Country:US
Mailing Address - Phone:864-591-0992
Mailing Address - Fax:864-591-0776
Practice Address - Street 1:1241 BOILING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-2258
Practice Address - Country:US
Practice Address - Phone:864-591-0992
Practice Address - Fax:864-591-0776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2944Medicaid
SCGP2944Medicaid
SC8101Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER