Basic Information
Provider Information | |||||||||
NPI: | 1578516043 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNION HOSPITAL DISTRICT CAROLINAS HEALTH ASSOCIATES - SOUTH M | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CENTER FOR FAMILY HEALTHCARE, P. A. | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 801 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | UNION | ||||||||
State: | SC | ||||||||
PostalCode: | 293792717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8644298029 | ||||||||
FaxNumber: | 8644293515 | ||||||||
Practice Location | |||||||||
Address1: | 801 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | UNION | ||||||||
State: | SC | ||||||||
PostalCode: | 293792717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8644298029 | ||||||||
FaxNumber: | 8644293515 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2006 | ||||||||
LastUpdateDate: | 06/21/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUSH | ||||||||
AuthorizedOfficialFirstName: | JEFF | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8644292601 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | GP1304 | 05 | SC |   | MEDICAID | 20020245 | 01 | SC | SELECT HEALTH MEDICAID HO | OTHER | DG6642 | 01 | SC | MEDICARE RAILROAD | OTHER | DG6642 | 01 | SC | RAILROAD MEDICARE | OTHER |