Basic Information
Provider Information | |||||||||
NPI: | 1073688057 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LORIS COMMUNITY HOSPITAL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LORIS HEALTHCARE SYSTEM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3655 MITCHELL ST | ||||||||
Address2: | BOX 690001 | ||||||||
City: | LORIS | ||||||||
State: | SC | ||||||||
PostalCode: | 295699601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437167596 | ||||||||
FaxNumber: | 8437167093 | ||||||||
Practice Location | |||||||||
Address1: | 3655 MITCHELL ST | ||||||||
Address2: | BOX 690001 | ||||||||
City: | LORIS | ||||||||
State: | SC | ||||||||
PostalCode: | 295699601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437167596 | ||||||||
FaxNumber: | 8437167093 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2006 | ||||||||
LastUpdateDate: | 05/25/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TODD | ||||||||
AuthorizedOfficialFirstName: | FRED | ||||||||
AuthorizedOfficialMiddleName: | O | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VP/CFO | ||||||||
AuthorizedOfficialTelephone: | 8437167271 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | HTL033 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
ID | Type | State | Issuer | Description | 400649 | 05 | SC |   | MEDICAID |