Basic Information
| Provider Information | |||||||||
| NPI: | 1467810937 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMTER FAMILY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUMTER FAMILY HEALTH CENTER - DENTAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1278 N LAFAYETTE DR | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291502964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037744500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 616 BULTMAN DR | ||||||||
| Address2: | SUITE #A | ||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291502593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037744500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2016 | ||||||||
| LastUpdateDate: | 01/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | ANNIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8037744500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMTER FAMILY HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 7124 | 01 | SC | MEDICARE | OTHER | FQC048 | 05 | SC | MEDICAID |