Basic Information
| Provider Information | |||||||||
| NPI: | 1144248097 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEXINGTON COUNTY HEALTH SERV | ||||||||
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| OtherOrganizationName: | LEXINGTON MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 896239 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282896239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037912000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2720 SUNSET BLVD | ||||||||
| Address2: | ATTN CREDENTIALING | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291694810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037912000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | SARVIS | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP | ||||||||
| AuthorizedOfficialTelephone: | 8037912000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LEXINGTON COUNTY HEALTH SERV | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 208M00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 400738 | 05 | SC | MEDICAID | 578074077003 | 01 | SC | TRICARE | OTHER |