Basic Information
Provider Information | |||||||||
NPI: | 1275953218 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GREENVILLE HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GHS CANCER INST-SPARTANBURG | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 INDEPENDENCE PT | ||||||||
Address2: | STE 212 | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296154545 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8647976400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 120 DILLON DR | ||||||||
Address2: |   | ||||||||
City: | SPARTANBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 293071018 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8646995700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2014 | ||||||||
LastUpdateDate: | 01/15/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 01/05/2015 | ||||||||
NPIReactivationDate: | 01/15/2015 | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RIORDAN | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | C. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 8644557978 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | HTL343 | SC | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 400783 | 05 | SC |   | MEDICAID | 6510325 | 01 | SC | AETNA ID | OTHER | GP2859 | 05 | SC |   | MEDICAID | 111717 | 05 | SC |   | MEDICAID | CB9553 | 01 | SC | MEDICARE RAILROAD | OTHER | CD7464 | 01 | SC | MEDICARE RAILROAD | OTHER | CI4624 | 01 | SC | MEDICARE RAILROAD | OTHER | 354643 | 05 | SC |   | MEDICAID | 42D0665869 | 01 | SC | CLIA | OTHER |