1770895674 NPI number — CHESTERFIELD-MARLBORO LP

Table of content: (NPI 1770895674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770895674 NPI number — CHESTERFIELD-MARLBORO LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHESTERFIELD-MARLBORO LP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MARLBORO PARK HOSPITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770895674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 689022
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT DEPARTMENT
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37068-9022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-304-1079
Provider Business Mailing Address Fax Number:
615-469-6629

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1138 CHERAW HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENNETTSVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29512-2466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-454-8400
Provider Business Practice Location Address Fax Number:
843-479-5860
Provider Enumeration Date:
07/08/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BREWER
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
877-892-9813

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 203749 . This is a "UNISON" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 5916149 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 400541 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8053756 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".