Provider Demographics
NPI:1417909037
Name:SPARTANBURG REGIONAL MED CTR
Entity Type:Organization
Organization Name:SPARTANBURG REGIONAL MED CTR
Other - Org Name:SURGICAL ASSOCIATES OF SPARTANBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HILLERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-560-4057
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:100 E WOOD ST
Practice Address - Street 2:SUITE 301
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3004
Practice Address - Country:US
Practice Address - Phone:864-560-7070
Practice Address - Fax:864-560-4413
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARTANBURG REGIONAL HEALTH SERVICES DISTRICT INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCN1627OtherRAILROAD MEDICARE GROUP #
NC5903624Medicaid
SCGP1118Medicaid
SC=========-099OtherBLUE CROSS BLUE SHIELD
NC5903624Medicaid
SCGP1118Medicaid