Provider Demographics
NPI:1104812692
Name:FLEETWOOD INTERNAL MEDICINE PA
Entity type:Organization
Organization Name:FLEETWOOD INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:STROUD
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:864-855-1036
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:PICKENS
Mailing Address - State:SC
Mailing Address - Zip Code:29671-0309
Mailing Address - Country:US
Mailing Address - Phone:864-850-1441
Mailing Address - Fax:864-850-1482
Practice Address - Street 1:109B FLEETWOOD DR
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-2019
Practice Address - Country:US
Practice Address - Phone:864-855-1036
Practice Address - Fax:864-855-3318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8878207QA0401X
SC9099207RC0000X
SC851207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA4726Medicaid
SCPA4726Medicaid