Basic Information
| Provider Information | |||||||||
| NPI: | 1578622478 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHESTERFIELD CLINIC CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CAROLINA SURGICAL PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 S DOCTORS DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CHERAW | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295207113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433209086 | ||||||||
| FaxNumber: | 8433209087 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 S DOCTORS DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CHERAW | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295207113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433209086 | ||||||||
| FaxNumber: | 8433209087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 09/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 6154657626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHESTERFIELD CLINIC CORP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | GP1883 | 05 | SC | MEDICAID | GP3624 | 05 | SC | MEDICAID |