Basic Information
| Provider Information | |||||||||
| NPI: | 1366521874 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLARENDON MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PALMETTO PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 137 | ||||||||
| Address2: | |||||||||
| City: | MANNING | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291023149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034355257 | ||||||||
| FaxNumber: | 8034355259 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 BOZARD ST | ||||||||
| Address2: | |||||||||
| City: | MANNING | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291022935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034355257 | ||||||||
| FaxNumber: | 8034355259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 01/31/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRYSON | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR COMMUNITY CLINICS | ||||||||
| AuthorizedOfficialTelephone: | 8034355270 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLARENDON MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHC 161 | 05 | SC | MEDICAID |