Provider Demographics
NPI:1184652794
Name:SPARTANBURG REGIONAL MED CTR
Entity Type:Organization
Organization Name:SPARTANBURG REGIONAL MED CTR
Other - Org Name:PALMETTO PEDIATRIC SPECIALTIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HILLERS
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
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:2755 S HIGHWAY 14
Practice Address - Street 2:SUITE 1200H
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4902
Practice Address - Country:US
Practice Address - Phone:864-849-9464
Practice Address - Fax:864-560-4413
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARTANBURG REGIONAL HEALTH SSERVICES DISTRICT INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-30
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1118Medicaid
SC=========098OtherBCBS GROUP#
SCGP1118Medicaid