Provider Demographics
NPI:1578622478
Name:CHESTERFIELD CLINIC CORP
Entity Type:Organization
Organization Name:CHESTERFIELD CLINIC CORP
Other - Org Name:CAROLINA SURGICAL PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7626
Mailing Address - Street 1:715 S DOCTORS DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHERAW
Mailing Address - State:SC
Mailing Address - Zip Code:29520-7113
Mailing Address - Country:US
Mailing Address - Phone:843-320-9086
Mailing Address - Fax:843-320-9087
Practice Address - Street 1:715 S DOCTORS DR
Practice Address - Street 2:SUITE C
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520-7113
Practice Address - Country:US
Practice Address - Phone:843-320-9086
Practice Address - Fax:843-320-9087
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESTERFIELD CLINIC CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-06
Last Update Date:2007-09-20
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
SCGP1883Medicaid
SCGP3624Medicaid
SC6532Medicare PIN
SC7625Medicare PIN