Provider Demographics
NPI:1104157718
Name:OAKTREE MEDICAL CENTRE, PC
Entity type:Organization
Organization Name:OAKTREE MEDICAL CENTRE, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-343-2611
Mailing Address - Street 1:P.O. BOX 484
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-4848
Mailing Address - Country:US
Mailing Address - Phone:864-855-1633
Mailing Address - Fax:864-855-1323
Practice Address - Street 1:108 MONTGOMERY DRIVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-3334
Practice Address - Country:US
Practice Address - Phone:864-225-5597
Practice Address - Fax:864-225-5835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2763Medicaid
SCGP2763Medicaid