Provider Demographics
NPI:1093990707
Name:CLEMSON UNIVERSITY CLEMSON RURAL HEALTH
Entity Type:Organization
Organization Name:CLEMSON UNIVERSITY CLEMSON RURAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:GIMBEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:864-656-1896
Mailing Address - Street 1:101 EDWARDS HALL
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29634-0001
Mailing Address - Country:US
Mailing Address - Phone:864-656-5520
Mailing Address - Fax:843-985-9562
Practice Address - Street 1:200 BOOKER DR
Practice Address - Street 2:
Practice Address - City:WALHALLA
Practice Address - State:SC
Practice Address - Zip Code:29691-2278
Practice Address - Country:US
Practice Address - Phone:864-656-3076
Practice Address - Fax:843-985-9562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1885Medicaid
SC6575Medicare PIN