Provider Demographics
NPI:1902083058
Name:ANGEL OAK FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:ANGEL OAK FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:LEONARA
Authorized Official - Last Name:BAER
Authorized Official - Suffix:
Authorized Official - Credentials:FNPC
Authorized Official - Phone:843-559-1938
Mailing Address - Street 1:PO BOX 336
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29457-0336
Mailing Address - Country:US
Mailing Address - Phone:843-559-1938
Mailing Address - Fax:
Practice Address - Street 1:1816 BOHICKET RD STE F
Practice Address - Street 2:
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-3318
Practice Address - Country:US
Practice Address - Phone:843-559-1938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRHC153261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC428975Medicare Oscar/Certification