Provider Demographics
NPI:1326089590
Name:CLARENDON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:CLARENDON MEMORIAL HOSPITAL
Other - Org Name:MANNING MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR COMMUNITY CLINICS
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NETTLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-435-5270
Mailing Address - Street 1:50 HOSPITAL ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102
Mailing Address - Country:US
Mailing Address - Phone:803-435-5250
Mailing Address - Fax:803-435-5255
Practice Address - Street 1:50 HOSPITAL ST
Practice Address - Street 2:SUITE 4
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102
Practice Address - Country:US
Practice Address - Phone:803-435-5250
Practice Address - Fax:803-435-5255
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLARENDON MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-09
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========006OtherBCBS ID WITH SUFFIX
SC420069Medicare Oscar/Certification
SC7603Medicare PIN
SC=========006OtherBCBS ID WITH SUFFIX