Provider Demographics
NPI:1225435134
Name:CLARENDON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:CLARENDON MEMORIAL HOSPITAL
Other - Org Name:CLARENDON PEDIATRIC ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAUGHNESSY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-435-3239
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-3153
Mailing Address - Country:US
Mailing Address - Phone:803-435-5248
Mailing Address - Fax:803-435-5288
Practice Address - Street 1:50 E HOSPITAL ST
Practice Address - Street 2:STE 4B
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3149
Practice Address - Country:US
Practice Address - Phone:803-433-8419
Practice Address - Fax:803-433-8417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6760Medicaid
SCE249Medicare PIN