Basic Information
| Provider Information | |||||||||
| NPI: | 1851608368 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNION HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CAROLINAS HEALTH ASSOCIATES FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 09/03/2010 | ||||||||
| LastUpdateDate: | 07/19/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETTIT | ||||||||
| AuthorizedOfficialFirstName: | TAMI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8644270331 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHC209 | 05 | SC | MEDICAID |