1275692501 NPI number — MARLBORO CLINIC CORP

Table of content: (NPI 1275692501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275692501 NPI number — MARLBORO CLINIC CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARLBORO 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:
6
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:
1275692501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1040 MARLBORO WAY
Provider Second Line Business Mailing Address:
SUITE 8
Provider Business Mailing Address City Name:
BENNETTSVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29512-2494
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-454-1100
Provider Business Mailing Address Fax Number:
843-454-0110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1040 MARLBORO WAY
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
BENNETTSVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29512-2494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-454-1100
Provider Business Practice Location Address Fax Number:
843-454-0110
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BREWER
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PROVIDER ENROLLMENT
Authorized Official Telephone Number:
800-709-7345

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; 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: "Y" .

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

  • Identifier: 89016G5 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57109350004 . This is a "BCBS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: GP4559 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP3861 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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