Basic Information
Provider Information | |||||||||
NPI: | 1356772776 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TANDEM HEALTH SC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TANDEM HEALTH - FAMILY MEDICINE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 250 | ||||||||
Address2: |   | ||||||||
City: | SUMTER | ||||||||
State: | SC | ||||||||
PostalCode: | 291510250 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037744500 | ||||||||
FaxNumber: | 8037744641 | ||||||||
Practice Location | |||||||||
Address1: | 319 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | SUMTER | ||||||||
State: | SC | ||||||||
PostalCode: | 291504258 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037744500 | ||||||||
FaxNumber: | 8033051466 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2013 | ||||||||
LastUpdateDate: | 10/14/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROWN | ||||||||
AuthorizedOfficialFirstName: | ANNIE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8037744500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SUMTER FAMILY HEALTH CENTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   | SC | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 42-1009 | 01 | SC | MEDICARE PROVIDER NUMBER | OTHER | 7124 | 01 | SC | MEDICARE ID | OTHER |