Basic Information
| Provider Information | |||||||||
| NPI: | 1700965217 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLARENDON MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | MANNING MEDICINE AND PALMETTO WOMEN'S HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 E. HOSPITAL ST. | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | MANNING | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291023149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034355257 | ||||||||
| FaxNumber: | 8034355259 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 E. HOSPITAL ST. | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | MANNING | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291023149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034355257 | ||||||||
| FaxNumber: | 8034355259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 06/30/2011 | ||||||||
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| AuthorizedOfficialLastName: | NETTLES | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/DIVISION MANAGER COMMUNITY | ||||||||
| AuthorizedOfficialTelephone: | 8034355270 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLARENDON MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 207V00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | RHC 532 | 05 | SC | MEDICAID |