Provider Demographics
NPI:1841252509
Name:SOUTHLAKE OBGYN LLC
Entity type:Organization
Organization Name:SOUTHLAKE OBGYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:GARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-359-3236
Mailing Address - Street 1:811 SOUTH LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072
Mailing Address - Country:US
Mailing Address - Phone:803-359-3236
Mailing Address - Fax:803-520-7584
Practice Address - Street 1:811 SOUTH LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072
Practice Address - Country:US
Practice Address - Phone:803-359-3236
Practice Address - Fax:803-520-7584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3626Medicaid
7544Medicare ID - Type Unspecified
SCGP3626Medicaid