| Ivy Park Family Medicine | |
|
111 Ivy Park Ln Suite C Lexington SC 29072-8289 | |
| (803) 785-4555 | |
| (803) 785-4556 |
| Full Name | Ivy Park Family Medicine |
|---|---|
| Speciality | Clinic/Center |
| Location | 111 Ivy Park Ln, Lexington, South Carolina |
| Authorized Official Name and Position | Wade Reynolds (PRESIDENT) |
| Authorized Official Contact | 8037854555 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Ivy Park Family Medicine 111 Ivy Park Lane Suite C Lexington SC 29072-8289 Ph: (803) 785-4555 | Ivy Park Family Medicine 111 Ivy Park Ln Suite C Lexington SC 29072-8289 Ph: (803) 785-4555 |
| NPI Number | 1518217389 |
|---|---|
| Provider Enumeration Date | 09/19/2012 |
| Last Update Date | 09/19/2012 |
| Medicare PECOS PAC ID | 3870743735 |
|---|---|
| Medicare Enrollment ID | O20121031000009 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1518217389 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | 0417 (South Carolina) | Primary |
| Provider Name | Wade Douglas Reynolds |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1780695965 PECOS PAC ID: 4082767397 Enrollment ID: I20090804000793 |
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