Basic Information
| Provider Information | |||||||||
| NPI: | 1417137803 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BERKELEY MEDICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONCKS CORNER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294612601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437611995 | ||||||||
| FaxNumber: | 8437613257 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONCKS CORNER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294612601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437611995 | ||||||||
| FaxNumber: | 8437613257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2007 | ||||||||
| LastUpdateDate: | 03/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | GIBBS | ||||||||
| AuthorizedOfficialFirstName: | ROSE | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 8437611995 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | RHC038 | 05 | SC | MEDICAID |