1740216191 NPI number — LORIS MEDICAL CENTER, PA

Table of content: (NPI 1740216191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740216191 NPI number — LORIS MEDICAL CENTER, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LORIS MEDICAL CENTER, 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:
1740216191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3439 CASEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LORIS
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29569-2903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-756-5300
Provider Business Mailing Address Fax Number:
843-756-6059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3439 CASEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LORIS
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29569-2903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-756-1582
Provider Business Practice Location Address Fax Number:
843-756-2042
Provider Enumeration Date:
06/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRAHAM
Authorized Official First Name:
WANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
843-756-5300

Provider Taxonomy Codes

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

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

  • Identifier: 4771 . This is a "PALMETTO MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: GP1053 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: CA6664 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 5950200 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0291J . This is a "NORTH CAROLINA BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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