Provider Demographics
NPI:1376546903
Name:CHESTERFIELD CLINIC CORP
Entity Type:Organization
Organization Name:CHESTERFIELD CLINIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7626
Mailing Address - Street 1:721 CHESTERFIELD HWY
Mailing Address - Street 2:
Mailing Address - City:CHERAW
Mailing Address - State:SC
Mailing Address - Zip Code:29520-7002
Mailing Address - Country:US
Mailing Address - Phone:843-921-1211
Mailing Address - Fax:843-921-1213
Practice Address - Street 1:721 CHESTERFIELD HWY
Practice Address - Street 2:
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520-7002
Practice Address - Country:US
Practice Address - Phone:843-921-1211
Practice Address - Fax:843-921-1213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3612Medicaid
SC6243Medicare PIN
SC7465Medicare PIN