Provider Demographics
NPI:1619051760
Name:GREENVILLE ENDOSCOPY CENTER INC
Entity Type:Organization
Organization Name:GREENVILLE ENDOSCOPY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-232-7338
Mailing Address - Street 1:PO BOX 8555
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29604-8555
Mailing Address - Country:US
Mailing Address - Phone:864-232-7338
Mailing Address - Fax:864-239-6645
Practice Address - Street 1:125 HALTON ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607
Practice Address - Country:US
Practice Address - Phone:864-232-7338
Practice Address - Fax:864-239-6645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCASF027261QA1903X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC410228Medicaid
SCQ292170001Medicare ID - Type Unspecified