Provider Demographics
NPI:1043528201
Name:SPARTANBURG MEDICAL CENTER
Entity Type:Organization
Organization Name:SPARTANBURG MEDICAL CENTER
Other - Org Name:MEDICAL GROUP OF THE CAROLINAS - FAMILY MEDICINE - LANDRUM - TRYON EST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MEINKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-560-6000
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:617 LAUREL LAKE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NC
Practice Address - Zip Code:28722-7401
Practice Address - Country:US
Practice Address - Phone:864-457-3838
Practice Address - Fax:864-560-9532
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARTANBURG REGIONAL HEALTH SERVICES DISTRICT INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-21
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916511Medicaid
NC5916511Medicaid