Provider Demographics
NPI:1043267263
Name:SPARTANBURG REGIONAL MED CTR
Entity Type:Organization
Organization Name:SPARTANBURG REGIONAL MED CTR
Other - Org Name:PALMETTO PEDIATRICS - NORTH GROVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-560-4057
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-2168
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1330 BOILING SPRINGS RD
Practice Address - Street 2:SUITE 1300
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-2244
Practice Address - Country:US
Practice Address - Phone:864-560-6345
Practice Address - Fax:864-560-6054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1118Medicaid
SC=========045OtherTRICARE GROUP
SC=========045OtherBLUE CROSS BLUE SHIELD GR