Basic Information
Provider Information | |||||||||
NPI: | 1891756458 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PORTSBRIDGE SOUTH CAROLINA, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PORTSBRIDGE HOSPICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1800 PHOENIX BLVD | ||||||||
Address2: | SUITE 128 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303495593 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6782845850 | ||||||||
FaxNumber: | 7709093406 | ||||||||
Practice Location | |||||||||
Address1: | 109 HOSPITAL DR W | ||||||||
Address2: |   | ||||||||
City: | WEST COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 291693405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8039392788 | ||||||||
FaxNumber: | 8039394640 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOSSFELD | ||||||||
AuthorizedOfficialFirstName: | ANITA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6782845856 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LMSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | HPC077 | SC | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | HSP055 | 05 | SC |   | MEDICAID |