Provider Demographics
NPI:1568616076
Name:SPARTANBURG REGIONAL MED CTR
Entity Type:Organization
Organization Name:SPARTANBURG REGIONAL MED CTR
Other - Org Name:PALMETTO HEMATOLOGY ONCOLOGY - EASTSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:AYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-560-6000
Mailing Address - Street 1:380 SERPENTINE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3066
Mailing Address - Country:US
Mailing Address - Phone:864-560-7050
Mailing Address - Fax:864-560-7057
Practice Address - Street 1:1702 SKYLYN DR
Practice Address - Street 2:UNIT C
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1040
Practice Address - Country:US
Practice Address - Phone:864-560-1402
Practice Address - Fax:864-560-1418
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARTANBURG REGIONAL HEALTH SERVICES DISTRICT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-11
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911413Medicaid
SCGP4991Medicaid
SCGP4991Medicaid