Basic Information
| Provider Information | |||||||||
| NPI: | 1487758041 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARION REGIONAL HEALTHCARE SYSTEM | ||||||||
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| OtherOrganizationName: | MARION MEDICAL CENTER OB/GYN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2845 E HIGHWAY 76 | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | MULLINS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295746037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434312740 | ||||||||
| FaxNumber: | 8434312197 | ||||||||
| Practice Location | |||||||||
| Address1: | 2845 E HIGHWAY 76 | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | MULLINS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295746037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434312740 | ||||||||
| FaxNumber: | 8434312197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 01/10/2008 | ||||||||
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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 | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 296147 | 05 | SC | MEDICAID |