Basic Information
| Provider Information | |||||||||
| NPI: | 1679564702 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KERSHAW HOSPITAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KERSHAWHEALTH HEALTHCARE PLACE AT BETHUNE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1315 ROBERTS ST | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290203737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034324311 | ||||||||
| FaxNumber: | 8037136384 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 SOUTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | BETHUNE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433346557 | ||||||||
| FaxNumber: | 8433346583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 10/14/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TURNER | ||||||||
| AuthorizedOfficialFirstName: | DAVIS | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6158449800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | HTL-101 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHC535 | 05 | SC | MEDICAID |