Provider Demographics
NPI:1245608934
Name:SPARTANBURG MEDICAL CENTER
Entity Type:Organization
Organization Name:SPARTANBURG MEDICAL CENTER
Other - Org Name:MEDICAL GROUP OF THE CAROLINAS - DERMATOLOGY - PELHAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MEINKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-560-6000
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
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 2050
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4902
Practice Address - Country:US
Practice Address - Phone:864-560-9715
Practice Address - Fax:864-560-9716
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARTANBURG REGIONAL HEALTH SERVICES DISTRICT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-11
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6965Medicaid
SCGP6965Medicaid