Basic Information
| Provider Information | |||||||||
| NPI: | 1023346681 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GEORGETOWN MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ANDREWS MEDICAL CENTER PEDIATRIC REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421718 | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294424203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432645253 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 S MORGAN AVE | ||||||||
| Address2: | |||||||||
| City: | ANDREWS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295102959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432645253 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2009 | ||||||||
| LastUpdateDate: | 11/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | KISER | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8435277000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.