Provider Demographics
NPI:1215156112
Name:GRANITEVILLE FAMILY MEDICAL CENTER LLC
Entity type:Organization
Organization Name:GRANITEVILLE FAMILY MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MAE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:ENGLEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-663-9224
Mailing Address - Street 1:1 HICKMAN ST
Mailing Address - Street 2:
Mailing Address - City:GRANITEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29829-2955
Mailing Address - Country:US
Mailing Address - Phone:803-663-9224
Mailing Address - Fax:803-663-8893
Practice Address - Street 1:1 HICKMAN ST
Practice Address - Street 2:
Practice Address - City:GRANITEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29829-2955
Practice Address - Country:US
Practice Address - Phone:803-663-9224
Practice Address - Fax:803-663-8893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8110Medicare PIN