Provider Demographics
NPI:1154336105
Name:MID CAROLINA INTERNAL MEDICINE ASSOC.LLC
Entity type:Organization
Organization Name:MID CAROLINA INTERNAL MEDICINE ASSOC.LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-520-5100
Mailing Address - Street 1:108 PALMETTO PARK BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7968
Mailing Address - Country:US
Mailing Address - Phone:803-520-5100
Mailing Address - Fax:803-520-5104
Practice Address - Street 1:108 PALMETTO PARK BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7968
Practice Address - Country:US
Practice Address - Phone:803-520-5100
Practice Address - Fax:803-520-5104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2341Medicaid
SCC15095OtherRAIL ROAD MEDICARE
SCGP2341Medicaid