Provider Demographics
NPI:1417137803
Name:BERKELEY MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:BERKELEY MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:D
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-761-1995
Mailing Address - Street 1:106 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-2601
Mailing Address - Country:US
Mailing Address - Phone:843-761-1995
Mailing Address - Fax:843-761-3257
Practice Address - Street 1:106 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-2601
Practice Address - Country:US
Practice Address - Phone:843-761-1995
Practice Address - Fax:843-761-3257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC038Medicaid
SC423851Medicare Oscar/Certification
SCRHC038Medicaid