Basic Information
| Provider Information | |||||||||
| NPI: | 1396779856 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARION MEDICAL GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295712025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434230760 | ||||||||
| FaxNumber: | 8434238138 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295712025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434230760 | ||||||||
| FaxNumber: | 8434238138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | TUCKER | ||||||||
| AuthorizedOfficialFirstName: | HAROLD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8434312405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHC075 | 05 | SC | MEDICAID |