Provider Demographics
NPI:1275692501
Name:MARLBORO CLINIC CORP
Entity Type:Organization
Organization Name:MARLBORO CLINIC CORP
Other - Org Name:MARLBORO WOMEN'S HEALTH
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:800-709-7345
Mailing Address - Street 1:1040 MARLBORO WAY
Mailing Address - Street 2:SUITE 8
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-2494
Mailing Address - Country:US
Mailing Address - Phone:843-454-1100
Mailing Address - Fax:843-454-0110
Practice Address - Street 1:1040 MARLBORO WAY
Practice Address - Street 2:SUITE 8
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-2494
Practice Address - Country:US
Practice Address - Phone:843-454-1100
Practice Address - Fax:843-454-0110
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARLBORO CLINIC CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-06
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89016G5Medicaid
SC57109350004OtherBCBS
SCGP4559Medicaid
SCGP3861Medicaid
SCGP4559Medicaid
NC89016G5Medicaid
SC57109350004OtherBCBS