Basic Information
Provider Information | |||||||||
NPI: | 1376595041 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTH CAROLINA DEPT OF MENTAL HEALTH ACCOUNTING OFFICE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PATRICK B HARRIS PSYCHIATRIC HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 485 | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292020485 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8038988405 | ||||||||
FaxNumber: | 8038988526 | ||||||||
Practice Location | |||||||||
Address1: | 130 HIGHWAY 252 | ||||||||
Address2: |   | ||||||||
City: | ANDERSON | ||||||||
State: | SC | ||||||||
PostalCode: | 296215054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8038988405 | ||||||||
FaxNumber: | 8038988526 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 09/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BELLAMY | ||||||||
AuthorizedOfficialFirstName: | VERSIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DEPUTY DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8039355761 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SOUTH CAROLINA DEPT OF MENTAL HEALTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X |   |   | Y |   | Hospitals | Psychiatric Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 461878 | 05 | SC |   | MEDICAID | GP2683 | 05 | SC |   | MEDICAID |