Provider Demographics
NPI:1427253897
Name:HUBER, LARA MAE HOURANI (MD)
Entity type:Individual
Prefix:
First Name:LARA MAE
Middle Name:HOURANI
Last Name:HUBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE A200
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-5004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC299482080P0216X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC299484Medicaid