1447383831 NPI number — CLEMSON EYE, PA

Table of content: (NPI 1447383831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447383831 NPI number — CLEMSON EYE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEMSON EYE, PA
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:
Provider Other Organization Name Type Code:
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:
1447383831
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 SOUTHERN CENTER CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EASLEY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29642-1533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-855-6800
Provider Business Mailing Address Fax Number:
864-855-6850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 PELHAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29615-3111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-268-1000
Provider Business Practice Location Address Fax Number:
864-292-2020
Provider Enumeration Date:
03/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GILLESPIE
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
FINANCE MANAGER
Authorized Official Telephone Number:
864-633-1051

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  17209 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DA9729 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: PA1747 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: CH3387 . This is a "MEDICARE RAILROAD GROUP" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 9429296 . This is a "MULTIPLAN GROUP" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 1252210001 . This is a "DMERC MAC SUPPLIER ID" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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