Provider Demographics
NPI:1437346913
Name:ABBEVILLE COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:ABBEVILLE COUNTY MEMORIAL HOSPITAL
Other - Org Name:ABBEVILLE INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-366-3279
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-0010
Mailing Address - Country:US
Mailing Address - Phone:864-366-3279
Mailing Address - Fax:864-366-0818
Practice Address - Street 1:901 W GREENWOOD ST
Practice Address - Street 2:SUITE 5
Practice Address - City:ABBEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29620-5717
Practice Address - Country:US
Practice Address - Phone:864-366-9938
Practice Address - Fax:864-366-0818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2023-01-06
Deactivation Date:2020-06-02
Deactivation Code:
Reactivation Date:2021-06-10
Provider Licenses
StateLicense IDTaxonomies
261QM2500X
SC423442261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4736Medicaid
SCRHC549Medicaid
SC42-3442OtherMEDICARE RHC
SCRHC549Medicaid
3255Medicare PIN