Basic Information
| Provider Information | |||||||||
| NPI: | 1346262961 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHESTERFIELD CLINIC CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CAROLINA PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 CLYDE AVE | ||||||||
| Address2: | |||||||||
| City: | CHERAW | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295203029 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 309 CLYDE AVE | ||||||||
| Address2: | |||||||||
| City: | CHERAW | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295203029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439211211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 09/20/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 6154657626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHESTERFIELD CLINIC CORP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | GP4534 | 05 | SC | MEDICAID |