Provider Demographics
NPI:1649387077
Name:EDGEFIELD MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:EDGEFIELD MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARI
Authorized Official - Middle Name:M
Authorized Official - Last Name:REEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-637-3146
Mailing Address - Street 1:200 RIDGE MEDICAL PLAZA RD
Mailing Address - Street 2:
Mailing Address - City:EDGEFIELD
Mailing Address - State:SC
Mailing Address - Zip Code:29824-4530
Mailing Address - Country:US
Mailing Address - Phone:803-637-3146
Mailing Address - Fax:803-637-3169
Practice Address - Street 1:200 RIDGE MEDICAL PLAZA RD
Practice Address - Street 2:
Practice Address - City:EDGEFIELD
Practice Address - State:SC
Practice Address - Zip Code:29824-4530
Practice Address - Country:US
Practice Address - Phone:803-637-3146
Practice Address - Fax:803-637-3169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC207Q00000XOtherTAXONOMY
SCPA0267Medicaid
SCH73241Medicare UPIN
SCH98434Medicare UPIN
SCPA0267Medicaid
SCD17852Medicare UPIN
SC207Q00000XOtherTAXONOMY
SCB92040Medicare UPIN