Provider Demographics
NPI:1477938777
Name:SPARTANBURG MEDICAL CENTER
Entity Type:Organization
Organization Name:SPARTANBURG MEDICAL CENTER
Other - Org Name:MEDICAL GROUP OF THE CAROLINAS - FAMILY MEDICINE - MOUNTAIN PARK VILLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MEINKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-560-6000
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 BOTANICAL CIR
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-7112
Practice Address - Country:US
Practice Address - Phone:864-849-9210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARTANBURG REGIONAL HEALTH SERVICES DISTRICT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-28
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6918Medicaid
SC5019Medicare PIN