Basic Information
| Provider Information | |||||||||
| NPI: | 1962522326 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID-CAROLINA HOSPITAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE CITY COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8087991700 | ||||||||
| FaxNumber: | 8032543678 | ||||||||
| Practice Location | |||||||||
| Address1: | 258 N RON MCNAIR BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295602462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433742036 | ||||||||
| FaxNumber: | 8433745111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MEGNA | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8037991700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ESQ | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | HTL897 | SC | Y | Hospitals | General Acute Care Hospital |
No ID Information.