Provider Demographics
NPI:1154489706
Name:CHESTERFIELD CLINIC CORP
Entity Type:Organization
Organization Name:CHESTERFIELD CLINIC CORP
Other - Org Name:PRIMARY CARE OF CHERAW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7626
Mailing Address - Street 1:34 FOUNDRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:CHERAW
Mailing Address - State:SC
Mailing Address - Zip Code:29520-2500
Mailing Address - Country:US
Mailing Address - Phone:843-537-7074
Mailing Address - Fax:843-537-2744
Practice Address - Street 1:34 FOUNDRY HILL RD
Practice Address - Street 2:
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520-2500
Practice Address - Country:US
Practice Address - Phone:843-537-7074
Practice Address - Fax:843-537-2744
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESTERFIELD CLINIC CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-05
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2502Medicaid
SCGP3624Medicaid
SC7625Medicare PIN
SCGP3624Medicaid