1164454435 NPI number — CHESTERFIELD CLINIC CORP

Table of content: (NPI 1164454435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164454435 NPI number — CHESTERFIELD CLINIC CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHESTERFIELD CLINIC CORP
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:
1164454435
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
715 S DOCTORS DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
CHERAW
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29520-7113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 S DOCTORS DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CHERAW
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29520-7113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-537-3622
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BREWER
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
DIRECTOR PROVIDER ENROLLMENT
Authorized Official Telephone Number:
615-465-7626

Provider Taxonomy Codes

  • 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: "Y" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GP1883 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5950784 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5900377 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5950778 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP4535 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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