Provider Demographics
NPI:1225258635
Name:MARLBORO CLINIC CORP
Entity Type:Organization
Organization Name:MARLBORO CLINIC CORP
Other - Org Name:WOMEN'S HEALTH SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position: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 1:7100 COMMERCE WAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2829
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:
Practice Address - Street 1:1076 MARLBORO WAY
Practice Address - Street 2:SUITE 1
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-2495
Practice Address - Country:US
Practice Address - Phone:843-454-2294
Practice Address - Fax:843-454-2342
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARLBORO CLINIC CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3861Medicaid
SCGP3861Medicaid
SCGRP5345Medicare PIN
SC5345Medicare PIN
DB5409Medicare PIN