Provider Demographics
NPI:1124115886
Name:DILLON INTERNAL MEDICINE ASSOCIATES PA
Entity type:Organization
Organization Name:DILLON INTERNAL MEDICINE ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-774-2478
Mailing Address - Street 1:705 N 8TH AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-2549
Mailing Address - Country:US
Mailing Address - Phone:843-774-2478
Mailing Address - Fax:843-774-0293
Practice Address - Street 1:705 N 8TH AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-2549
Practice Address - Country:US
Practice Address - Phone:843-774-2478
Practice Address - Fax:843-774-0293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7901443Medicaid
SCPA8526Medicaid
SC2620Medicare ID - Type Unspecified
NC7901443Medicaid