Provider Demographics
NPI:1508903394
Name:ROSA CLARK MEDICAL CENTER
Entity Type:Organization
Organization Name:ROSA CLARK MEDICAL CENTER
Other - Org Name:ROSA CLARK MEDICAL CLINIC ASSOCIATION, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:SHANNON
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-614-5617
Mailing Address - Street 1:301 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29672-9491
Mailing Address - Country:US
Mailing Address - Phone:864-614-5617
Mailing Address - Fax:864-882-4478
Practice Address - Street 1:301 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672
Practice Address - Country:US
Practice Address - Phone:864-882-4629
Practice Address - Fax:864-882-4478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X, 333600000X
SC31293336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125083OtherPK
42-1049Medicare PIN